Provider Demographics
NPI:1619330453
Name:GERIDEAU, MARY (LCSW-A)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GERIDEAU
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 GODWIN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3149
Mailing Address - Country:US
Mailing Address - Phone:910-674-4814
Mailing Address - Fax:
Practice Address - Street 1:2003 GODWIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3149
Practice Address - Country:US
Practice Address - Phone:910-674-4814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0102291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical