Provider Demographics
NPI:1487209649
Name:MCGOWAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCGOWAN
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 1:49 BELCREST RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-3305
Mailing Address - Country:US
Mailing Address - Phone:860-899-4060
Mailing Address - Fax:
Practice Address - Street 1:49 BELCREST RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-3305
Practice Address - Country:US
Practice Address - Phone:860-899-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2023-04-12
Deactivation Date:2022-05-10
Deactivation Code:
Reactivation Date:2022-10-03
Provider Licenses
StateLicense IDTaxonomies
CT3742101Y00000X
CT003742101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty