Provider Demographics
NPI: | 1821234956 |
---|---|
Name: | KANE, MARY (LCSW-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARY |
Middle Name: | |
Last Name: | KANE |
Suffix: | |
Gender: | F |
Credentials: | LCSW-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 6501 N CHARLES ST |
Mailing Address - Street 2: | ROOM D225 |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21204-6819 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-938-3464 |
Mailing Address - Fax: | 410-938-5131 |
Practice Address - Street 1: | 10085 RED RUN BLVD |
Practice Address - Street 2: | SUITE 306 |
Practice Address - City: | OWINGS MILLS |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21117-4836 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-581-7804 |
Practice Address - Fax: | 410-356-6507 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-12-18 |
Last Update Date: | 2017-01-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | 22462 | 1041C0700X |
NJ | 44SC05446400 | 101YM0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 00245836 | Medicaid | |
NY | 35446 A & B | Other | MEDICARE |