Provider Demographics
NPI:1235495573
Name:WORTHINGTON, MARY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 SOUTH OCEAN AVENUE
Mailing Address - Street 2:PATCHOGUE MEDFORD SCHOOL DISTRICT
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-687-6440
Mailing Address - Fax:
Practice Address - Street 1:241 SOUTH OCEAN AVENUE
Practice Address - Street 2:PATCHOGUE MEDFORD SCHOOL DISTRICT
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-687-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68013890103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist