Provider Demographics
NPI:1134631310
Name:DESANTIS, MARY (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:945 E HENRIETTA RD STE A-2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1419
Mailing Address - Country:US
Mailing Address - Phone:585-773-4396
Mailing Address - Fax:
Practice Address - Street 1:945 E HENRIETTA RD STE A-2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1419
Practice Address - Country:US
Practice Address - Phone:585-773-4396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-28
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18789101YA0400X
NY086207104100000X
NY0952961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty