Provider Demographics
NPI:1851666077
Name:JOHN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3600
Mailing Address - Country:US
Mailing Address - Phone:718-258-5450
Mailing Address - Fax:
Practice Address - Street 1:2233 NOSTRAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3045
Practice Address - Country:US
Practice Address - Phone:718-859-9760
Practice Address - Fax:718-859-9767
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health