Provider Demographics
NPI:1073601662
Name:MCCARTHY, MARY A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1448
Mailing Address - Country:US
Mailing Address - Phone:907-545-6645
Mailing Address - Fax:
Practice Address - Street 1:422 S WASHINGTON ST
Practice Address - Street 2:STE 3
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:907-545-6645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCSWS11041041C0700X
AK489101YP2500X
UT10144643-35011041C0700X
IDLCSW-363001041C0700X
AK11041041C0700X
GU125106H00000X
WYLCSW-11011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH2237Medicaid
AK1020986Medicaid
AK1020986Medicaid