Provider Demographics
NPI:1346339157
Name:HELLER, MARY B (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:HELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 THORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4633
Mailing Address - Country:US
Mailing Address - Phone:845-452-3714
Mailing Address - Fax:845-473-5451
Practice Address - Street 1:55 WILBUR BLVD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-3424
Practice Address - Country:US
Practice Address - Phone:845-452-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR012022-1302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN44441Medicare ID - Type Unspecified