Provider Demographics
NPI:1316209349
Name:MCCRAITH, MARYALICE (MS SP REG ED TVI)
Entity Type:Individual
Prefix:
First Name:MARYALICE
Middle Name:
Last Name:MCCRAITH
Suffix:
Gender:F
Credentials:MS SP REG ED TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-9734
Mailing Address - Country:US
Mailing Address - Phone:518-369-1330
Mailing Address - Fax:
Practice Address - Street 1:9 DEER RUN
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-9734
Practice Address - Country:US
Practice Address - Phone:518-369-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12189174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist