Provider Demographics
NPI:1437217403
Name:SHELLEY, MARY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:SHELLEY
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 1:109 PARK PL
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4028
Mailing Address - Country:US
Mailing Address - Phone:607-273-2312
Mailing Address - Fax:
Practice Address - Street 1:319 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4205
Practice Address - Country:US
Practice Address - Phone:607-273-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR043869-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPR043869OtherLCSW, CLINICAL SOCIAL WOR
NY9246OtherCASAC