Provider Demographics
NPI:1912955865
Name:PETERSEN-CLEARY, MARY-BETH (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARY-BETH
Middle Name:
Last Name:PETERSEN-CLEARY
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2201
Mailing Address - Country:US
Mailing Address - Phone:716-218-1400
Mailing Address - Fax:716-332-2820
Practice Address - Street 1:3370 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1425
Practice Address - Country:US
Practice Address - Phone:716-877-8822
Practice Address - Fax:716-874-5245
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000565181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000302141501OtherUNIVERA
NY000590325001OtherBLUECROSS/BLUESHIELD