Provider Demographics
NPI:1407857972
Name:MIRRO, MARY (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MIRRO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 STERLING CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2686
Mailing Address - Country:US
Mailing Address - Phone:219-805-7407
Mailing Address - Fax:
Practice Address - Street 1:1024 STERLING CT
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2686
Practice Address - Country:US
Practice Address - Phone:219-805-7407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041970A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200529940Medicaid