Provider Demographics
NPI:1346379708
Name:IANNOTTI, MARY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:IANNOTTI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 NIMITZ RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3716
Mailing Address - Country:US
Mailing Address - Phone:973-628-9394
Mailing Address - Fax:973-633-0001
Practice Address - Street 1:48 NIMITZ RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3716
Practice Address - Country:US
Practice Address - Phone:973-628-9394
Practice Address - Fax:973-633-0001
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00094200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0066354Medicaid
NJ0066354Medicaid