Provider Demographics
NPI:1275542722
Name:NIXON, MARY J (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:NIXON
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 E HAZELTINE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2829
Mailing Address - Country:US
Mailing Address - Phone:716-876-5130
Mailing Address - Fax:716-876-5130
Practice Address - Street 1:32 LANDERS RD
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2406
Practice Address - Country:US
Practice Address - Phone:716-597-6178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04211011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027123401OtherUNIVERA
NY000503631001OtherBLUE CROSS BLUE SHIELD
NY00027123401OtherUNIVERA