Provider Demographics
NPI:1376609628
Name:GIUDICE, MARY (LCSW CASAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:GIUDICE
Suffix:
Gender:F
Credentials:LCSW CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SI
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3224
Mailing Address - Country:US
Mailing Address - Phone:718-980-2048
Mailing Address - Fax:718-980-2048
Practice Address - Street 1:159 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SI
Practice Address - State:NY
Practice Address - Zip Code:10306-3224
Practice Address - Country:US
Practice Address - Phone:718-980-2048
Practice Address - Fax:718-980-2048
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0409191104100000X
NJ44SC00357400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014458581Medicaid
NY101351115Medicaid
NY101351115Medicaid