Provider Demographics
NPI:1730411109
Name:MCCARTHY, MARY CORLISS
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CORLISS
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7501
Mailing Address - Country:US
Mailing Address - Phone:508-559-0473
Mailing Address - Fax:508-427-5361
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-559-0473
Practice Address - Fax:508-427-5361
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2743171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2743OtherPROFESSIONAL CHILD CARE QUALIFICATION REGISTRY