Provider Demographics
NPI:1801231519
Name:GRESHAM, MARIE C (LMSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2522
Mailing Address - Country:US
Mailing Address - Phone:607-729-6206
Mailing Address - Fax:607-729-1858
Practice Address - Street 1:257 MAIN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2522
Practice Address - Country:US
Practice Address - Phone:607-729-6206
Practice Address - Fax:607-729-1858
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088710-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker