Provider Demographics
NPI:1790786374
Name:NIEBAUER, MARY JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:NIEBAUER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:MANFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:325 NEW CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-2418
Mailing Address - Country:US
Mailing Address - Phone:724-285-2501
Mailing Address - Fax:724-477-5038
Practice Address - Street 1:325 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-2418
Practice Address - Country:US
Practice Address - Phone:724-285-2501
Practice Address - Fax:724-477-5038
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS009247L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018591130001Medicaid
PAS94678Medicare UPIN
PA0018591130001Medicaid