Provider Demographics
NPI:1457463598
Name:HASBROUCK, MARY LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY LEE
Middle Name:
Last Name:HASBROUCK
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 1:45 ROUTE 25A STE A2
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1389
Mailing Address - Country:US
Mailing Address - Phone:631-821-5056
Mailing Address - Fax:631-821-5056
Practice Address - Street 1:45 ROUTE 25A STE A2
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1389
Practice Address - Country:US
Practice Address - Phone:631-821-5056
Practice Address - Fax:631-821-5056
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR022772-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01475396Medicaid
NY01475396Medicaid