Provider Demographics
NPI:1356643514
Name:DOUSHARM, MARY BRONDOU (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BRONDOU
Last Name:DOUSHARM
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 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:28 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1405
Practice Address - Country:US
Practice Address - Phone:315-287-2811
Practice Address - Fax:315-394-0097
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0828981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical