Provider Demographics
NPI:1336402338
Name:MARY CONNOLLY LMSW PC
Entity Type:Organization
Organization Name:MARY CONNOLLY LMSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-344-4981
Mailing Address - Street 1:92 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1812
Mailing Address - Country:US
Mailing Address - Phone:718-344-4981
Mailing Address - Fax:
Practice Address - Street 1:92 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-1812
Practice Address - Country:US
Practice Address - Phone:718-344-4981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075265252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency