Provider Demographics
NPI:1841451523
Name:DECOTIIS, MARY SUE (LCSW-R)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:DECOTIIS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:CHAPIN
Other - Last Name:DECOTIIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:127 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5474
Mailing Address - Country:US
Mailing Address - Phone:607-273-7494
Mailing Address - Fax:607-273-7484
Practice Address - Street 1:127 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5474
Practice Address - Country:US
Practice Address - Phone:607-273-7494
Practice Address - Fax:607-273-7484
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0382691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39703NMedicare PIN