Provider Demographics
NPI:1134281777
Name:OLSEN-LANZAFAME, MARY E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:OLSEN-LANZAFAME
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:124 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2131
Mailing Address - Country:US
Mailing Address - Phone:585-732-5310
Mailing Address - Fax:585-495-2146
Practice Address - Street 1:121 SULLYS TRL
Practice Address - Street 2:SUITE 5
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-732-5310
Practice Address - Fax:585-495-2146
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012566103T00000X, 103TC2200X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMDF487OtherPREFERRED CARE PROV ID
NYP040012566OtherBCBS PROVIDER ID
NM7799323OtherAETNA PROVIDER ID
NYP010012566OtherBLUE CHOICE PROVIDER ID