Provider Demographics
NPI:1376829119
Name:NG-TEDJASUKMANA, MARY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:NG-TEDJASUKMANA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:NG-TEDJASUKMANA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, PLLC
Mailing Address - Street 1:1863 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2549
Mailing Address - Country:US
Mailing Address - Phone:718-395-2064
Mailing Address - Fax:
Practice Address - Street 1:1863 W 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2549
Practice Address - Country:US
Practice Address - Phone:718-395-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081483-11041C0700X
NJ44SC057121001041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical