Provider Demographics
NPI:1619374634
Name:DAVID, MARY ELLEN (MA, LSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:DAVID
Suffix:
Gender:F
Credentials:MA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 MOGADORE RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-1504
Mailing Address - Country:US
Mailing Address - Phone:330-458-0393
Mailing Address - Fax:
Practice Address - Street 1:1620 MARKET AVE S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707
Practice Address - Country:US
Practice Address - Phone:330-458-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 00302301041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool