Provider Demographics
NPI:1942259619
Name:DURSO, MARY TEN BROECH (LICENSED PSYCHOLOGIS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TEN BROECH
Last Name:DURSO
Suffix:
Gender:F
Credentials:LICENSED PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 88 BOX 434
Mailing Address - Street 2:
Mailing Address - City:POCONO LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18347-9512
Mailing Address - Country:US
Mailing Address - Phone:570-646-0870
Mailing Address - Fax:570-403-5079
Practice Address - Street 1:359 S MOUNTAIN BLVD
Practice Address - Street 2:SUITE C2
Practice Address - City:MOUTAINTOP
Practice Address - State:PA
Practice Address - Zip Code:18707
Practice Address - Country:US
Practice Address - Phone:570-403-5080
Practice Address - Fax:570-403-5079
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006873L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016193400002Medicaid
PA080953OtherFIRST PRIORITY HLTH
PA2056962OtherCIGNA
PADV585250Medicare ID - Type Unspecified