Provider Demographics
NPI:1134617673
Name:GENSLER, MARYANN ELIZABETH
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:ELIZABETH
Last Name:GENSLER
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:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-0193
Mailing Address - Country:US
Mailing Address - Phone:631-407-3505
Mailing Address - Fax:631-407-3505
Practice Address - Street 1:11900 SOUNDVIEW AVE
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-2721
Practice Address - Country:US
Practice Address - Phone:631-276-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096781104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker