Provider Demographics
NPI:1073934527
Name:FREITAS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FREITAS
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 1:351 SAINT NICHOLAS AVE APT 54
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7651
Mailing Address - Country:US
Mailing Address - Phone:646-330-8035
Mailing Address - Fax:
Practice Address - Street 1:351 SAINT NICHOLAS AVE APT 54
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7651
Practice Address - Country:US
Practice Address - Phone:646-330-8035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY774832131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist