Provider Demographics
NPI:1558813634
Name:SOMOGYI, MARY TERESA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:TERESA
Last Name:SOMOGYI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 PARKSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:USA
Mailing Address - Zip Code:10901
Mailing Address - Country:UM
Mailing Address - Phone:914-483-9896
Mailing Address - Fax:
Practice Address - Street 1:625 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4919
Practice Address - Country:US
Practice Address - Phone:914-483-9896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0039111171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0039111OtherLICENSE NUMBER