Provider Demographics
NPI:1639329808
Name:DEMUNN, MARY (BS, CASAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEMUNN
Suffix:
Gender:F
Credentials:BS, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2130
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-753-0286
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2130
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:607-753-0286
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21308101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01079267Medicaid