Provider Demographics
NPI:1831280544
Name:MERCURIO, MARY J (LMHC, LCDP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:MERCURIO
Suffix:
Gender:F
Credentials:LMHC, LCDP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:MERCURIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:11 BLUEBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921
Mailing Address - Country:US
Mailing Address - Phone:401-943-0000
Mailing Address - Fax:401-943-0314
Practice Address - Street 1:75 SOCKANOSSET CROSS ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920
Practice Address - Country:US
Practice Address - Phone:401-398-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP00288101YA0400X
RILCDP 288101YA0400X
RIMHC 000287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI413292OtherBLUE CHIP
RI0000031312OtherBLUE CROSS
RIMM58994Medicaid