Provider Demographics
NPI:1043788607
Name:MCCANN, MARY (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCANN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RARITAN AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-3667
Mailing Address - Country:US
Mailing Address - Phone:732-227-0070
Mailing Address - Fax:
Practice Address - Street 1:1001 RARITAN AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-3667
Practice Address - Country:US
Practice Address - Phone:732-227-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00320000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health