Provider Demographics
NPI:1326101643
Name:BURNS, MARY JO (PHD, APRN, BC-PMH)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:PHD, APRN, BC-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2832
Mailing Address - Country:US
Mailing Address - Phone:315-339-3597
Mailing Address - Fax:315-339-1844
Practice Address - Street 1:110 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2832
Practice Address - Country:US
Practice Address - Phone:315-339-3597
Practice Address - Fax:315-339-1844
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRN158632NY103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3191621OtherGHI
NY121197OtherVALUE OPTIONS
NY121197OtherVALUE OPTIONS