Provider Demographics
NPI:1609320829
Name:MENDICINO, MARA (CASAC-G)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:MENDICINO
Suffix:
Gender:F
Credentials:CASAC-G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:AIRMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-369-9701
Mailing Address - Fax:
Practice Address - Street 1:100 ROUTE 59
Practice Address - Street 2:
Practice Address - City:AIRMONT
Practice Address - State:NY
Practice Address - Zip Code:10901-4927
Practice Address - Country:US
Practice Address - Phone:845-369-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)