Provider Demographics
NPI:1003198896
Name:GEORGETTE, MARY M (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:GEORGETTE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PLAINS RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2573
Mailing Address - Country:US
Mailing Address - Phone:203-581-2068
Mailing Address - Fax:
Practice Address - Street 1:57 PLAINS RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-2573
Practice Address - Country:US
Practice Address - Phone:203-581-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001440106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist