Provider Demographics
NPI:1518188952
Name:KENT-LICARDI, MARA ANN (LCSWR)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:ANN
Last Name:KENT-LICARDI
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-1222
Mailing Address - Country:US
Mailing Address - Phone:914-805-7677
Mailing Address - Fax:
Practice Address - Street 1:200 MIDWAY PARK DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2642
Practice Address - Country:US
Practice Address - Phone:845-343-7274
Practice Address - Fax:845-343-4545
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR074102-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical