Provider Demographics
NPI:1629277272
Name:MCKENNA CLIFFORD, MARY SUZANNE (CSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUZANNE
Last Name:MCKENNA CLIFFORD
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:M
Other - Middle Name:SUZANNE
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:85 GERARD AVE W
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1226
Mailing Address - Country:US
Mailing Address - Phone:516-382-7226
Mailing Address - Fax:
Practice Address - Street 1:85 GERARD AVE W
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1226
Practice Address - Country:US
Practice Address - Phone:516-382-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP015619-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical