Provider Demographics
NPI:1891243218
Name:MCKILLOP, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCKILLOP
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 1:14379 RT 9W
Mailing Address - Street 2:CIRCLE OF FRIENDS
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-3103
Mailing Address - Country:US
Mailing Address - Phone:518-756-3124
Mailing Address - Fax:518-756-9476
Practice Address - Street 1:14379 RT 9W
Practice Address - Street 2:CIRCLE OF FRIENDS
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143-3103
Practice Address - Country:US
Practice Address - Phone:518-756-3124
Practice Address - Fax:518-756-9476
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist