Provider Demographics
NPI:1912538802
Name:MYERS, MARY CORDELIA (PC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CORDELIA
Last Name:MYERS
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 OREGON TRL
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-5325
Mailing Address - Country:US
Mailing Address - Phone:917-386-3286
Mailing Address - Fax:
Practice Address - Street 1:946 OREGON TRL
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-5325
Practice Address - Country:US
Practice Address - Phone:917-386-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral