Provider Demographics
NPI:1477006005
Name:CREA, MARY C (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:CREA
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 1:636 DELAWARE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2416
Mailing Address - Country:US
Mailing Address - Phone:518-248-5314
Mailing Address - Fax:
Practice Address - Street 1:636 DELAWARE AVE STE 2
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-2416
Practice Address - Country:US
Practice Address - Phone:518-248-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0845441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDC61041PMedicaid