Provider Demographics
NPI:1508955022
Name:MARY ANDERSON LCSW PC
Entity Type:Organization
Organization Name:MARY ANDERSON LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-941-9494
Mailing Address - Street 1:9 BAYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1727
Mailing Address - Country:US
Mailing Address - Phone:631-941-9494
Mailing Address - Fax:631-941-9494
Practice Address - Street 1:9 BAYWOOD LN
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1727
Practice Address - Country:US
Practice Address - Phone:631-941-9494
Practice Address - Fax:631-941-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR05054211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY61020463081Medicaid
NYN2W951Medicare ID - Type Unspecified