Provider Demographics
NPI:1326242769
Name:DUANE, MARYELLYN (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARYELLYN
Middle Name:
Last Name:DUANE
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 E 85TH ST
Mailing Address - Street 2:OFFICE # 5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2140
Mailing Address - Country:US
Mailing Address - Phone:212-860-0042
Mailing Address - Fax:212-860-1342
Practice Address - Street 1:185 E 85TH ST
Practice Address - Street 2:OFFICE # 5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2140
Practice Address - Country:US
Practice Address - Phone:212-860-0042
Practice Address - Fax:212-860-1342
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6931103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV5573ZVQZ1Medicare PIN
NYV55731Medicare UPIN