Provider Demographics
NPI:1720601743
Name:WILLIAMS, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:WILLIAMS
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 1:693 PELTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3139
Mailing Address - Country:US
Mailing Address - Phone:646-776-3617
Mailing Address - Fax:
Practice Address - Street 1:693 PELTON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-3139
Practice Address - Country:US
Practice Address - Phone:646-776-3617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0410091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical