Provider Demographics
NPI:1811256472
Name:MAUBOUSSIN, MARIE-LUCILE (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:MARIE-LUCILE
Middle Name:
Last Name:MAUBOUSSIN
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6222
Mailing Address - Country:US
Mailing Address - Phone:607-227-3326
Mailing Address - Fax:
Practice Address - Street 1:501 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6148
Practice Address - Country:US
Practice Address - Phone:607-277-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048261-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7379617OtherNEW YORK STATE OFFICE OF REGISTRATION CERTIFICATE