Provider Demographics
NPI:1619593639
Name:SUMMERS, MARY COLLETTE (LBS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLETTE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:LBS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:COLLETTE
Other - Last Name:NICKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBS
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-2560
Mailing Address - Fax:717-812-2569
Practice Address - Street 1:781 FAR HILLS DR STE 600
Practice Address - Street 2:
Practice Address - City:NEW FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:17349-8404
Practice Address - Country:US
Practice Address - Phone:717-812-2560
Practice Address - Fax:717-812-2569
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002981101Y00000X
PAPC012855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH002981OtherLICENSED BEHAVIORAL SPECIALIST