Provider Demographics
NPI:1891279568
Name:MAURO, JACQUELINE (MS, NCSP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MAURO
Suffix:
Gender:F
Credentials:MS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DUVALL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3038
Mailing Address - Country:US
Mailing Address - Phone:631-875-8044
Mailing Address - Fax:
Practice Address - Street 1:17 DUVALL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-3038
Practice Address - Country:US
Practice Address - Phone:631-875-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool