Provider Demographics
NPI:1013067180
Name:BROUGHTON, MARY ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EMMY
Other - Middle Name:
Other - Last Name:BROUGHTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525
Mailing Address - Country:US
Mailing Address - Phone:845-255-8323
Mailing Address - Fax:
Practice Address - Street 1:243 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1325
Practice Address - Country:US
Practice Address - Phone:845-255-8323
Practice Address - Fax:845-255-5832
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02591811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGHI 7400885OtherGHI
NYGHI 7400885OtherGHI