Provider Demographics
NPI:1407918410
Name:ROBERTS, MARY ALICE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 5TH AVE
Mailing Address - Street 2:9 D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0130
Mailing Address - Country:US
Mailing Address - Phone:914-450-8676
Mailing Address - Fax:
Practice Address - Street 1:149 E 78TH ST
Practice Address - Street 2:ACKERMAN INSTITUTE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0405
Practice Address - Country:US
Practice Address - Phone:914-450-8676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075021104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940Medicaid
NY1285628552OtherAGENCY NPI
NYWVE061Medicare ID - Type UnspecifiedAGENCY MEDICARE PROVIDER#