Provider Demographics
NPI:1578605218
Name:MAVRONICOLAS, CAROL
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:MAVRONICOLAS
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 1:915 BROADWAY
Mailing Address - Street 2:SUITE 1309
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-7108
Mailing Address - Country:US
Mailing Address - Phone:212-780-9630
Mailing Address - Fax:212-253-7171
Practice Address - Street 1:915 BROADWAY
Practice Address - Street 2:SUITE 1309
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7108
Practice Address - Country:US
Practice Address - Phone:212-780-9630
Practice Address - Fax:212-253-7171
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO39508-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical