Provider Demographics
NPI:1871947150
Name:HARRIS, MARY DENISE (LCSW-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DENISE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:DENISE
Other - Last Name:CEDERBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-6629
Practice Address - Fax:774-443-7399
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD216841041C0700X
MA1227451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MDR968OtherCAREFIRST
MD346646OtherMANAGED HEALTH NETWORK/TRICARE
MD522156095OtherJOHNS HOPKINS HEALTH CARE
MD259147-0001OtherMAGELLAN BEHAVIORAL HEALTH
MD609500004Medicaid