Provider Demographics
NPI:1215231121
Name:VANDERZELL, MARA LADD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:LADD
Last Name:VANDERZELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARA
Other - Middle Name:VICTORIA
Other - Last Name:LADD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:6600 BUCKLAND DR
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2626
Mailing Address - Country:US
Mailing Address - Phone:315-797-6241
Mailing Address - Fax:315-749-7054
Practice Address - Street 1:1601 ARMORY DR
Practice Address - Street 2:BUILDING C
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5405
Practice Address - Country:US
Practice Address - Phone:315-797-6241
Practice Address - Fax:315-749-7054
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018838-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist