Provider Demographics
NPI:1689819542
Name:SOMMERS, MARILYNNE CAMILLE (NYS LICENSED CLIN)
Entity Type:Individual
Prefix:
First Name:MARILYNNE
Middle Name:CAMILLE
Last Name:SOMMERS
Suffix:
Gender:F
Credentials:NYS LICENSED CLIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 CODDINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-4308
Mailing Address - Fax:
Practice Address - Street 1:617 NORTH CAYUGA STREET
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-272-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY#072817-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical