Provider Demographics
NPI:1083863054
Name:CONAN, MARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:
Last Name:CONAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:WAITZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:320 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3139
Mailing Address - Country:US
Mailing Address - Phone:917-453-4798
Mailing Address - Fax:212-873-3468
Practice Address - Street 1:320 W 86TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3139
Practice Address - Country:US
Practice Address - Phone:917-453-4798
Practice Address - Fax:212-873-3468
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6187487103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist