Provider Demographics
NPI:1295774743
Name:BARRY, MARYANNE THERESA (LCSW-R)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:THERESA
Last Name:BARRY
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:MARYANNE
Other - Middle Name:THERESA
Other - Last Name:GROGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:142 WEST END AVENUE
Mailing Address - Street 2:#28 W
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6123
Mailing Address - Country:US
Mailing Address - Phone:646-505-1553
Mailing Address - Fax:
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:#PH
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:646-505-1553
Practice Address - Fax:718-837-5676
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070783104100000X
NYR0707831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP28860Medicare UPIN
NYNU6251Medicare PIN