Provider Demographics
NPI:1164146858
Name:ANASTASIA, MARY (LSW)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:ANASTASIA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 E OAK ST STE 2-2
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-2795
Mailing Address - Country:US
Mailing Address - Phone:217-530-5608
Mailing Address - Fax:309-981-8714
Practice Address - Street 1:1204 E OAK ST STE 2-2
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-2795
Practice Address - Country:US
Practice Address - Phone:217-530-5608
Practice Address - Fax:309-981-8714
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150108984104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker