Provider Demographics
NPI:1790731990
Name:EKWALL, MARY FORERO (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:FORERO
Last Name:EKWALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARIA DEL
Other - Middle Name:ROSARIO
Other - Last Name:FORERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2064 31 STREET
Mailing Address - Street 2:APT C8
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2528
Mailing Address - Country:US
Mailing Address - Phone:718-726-5451
Mailing Address - Fax:
Practice Address - Street 1:540 EAST 13 STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009
Practice Address - Country:US
Practice Address - Phone:212-387-7419
Practice Address - Fax:212-387-7432
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP0471751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01763455Medicaid
N3M811Medicare ID - Type Unspecified
505461Medicare UPIN
H15701Medicare UPIN