Provider Demographics
NPI:1477796266
Name:BATES, MARY E (LISW-SUPV)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BATES
Suffix:
Gender:
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PENNINGTON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2249
Mailing Address - Country:US
Mailing Address - Phone:330-428-2046
Mailing Address - Fax:
Practice Address - Street 1:2400 PENNINGTON ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2249
Practice Address - Country:US
Practice Address - Phone:330-428-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0800204-SUPV104100000X
OHI.08002041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10024Medicaid