Provider Demographics
NPI:1104026327
Name:LEONARDO, MARY GRACE (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GRACE
Last Name:LEONARDO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:G
Other - Last Name:ROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:250 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9747
Mailing Address - Country:US
Mailing Address - Phone:607-279-9034
Mailing Address - Fax:
Practice Address - Street 1:250 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9747
Practice Address - Country:US
Practice Address - Phone:607-279-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0697331041C0700X
NY5397760411041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY553866OtherVALUE OPTIONS