Provider Demographics
NPI:1962769307
Name:MARY ELLEN STAHR LCSW LLC
Entity type:Organization
Organization Name:MARY ELLEN STAHR LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:STAHR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:941-758-1636
Mailing Address - Street 1:3653 CORTEZ RD W
Mailing Address - Street 2:SUITE 110 H
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3168
Mailing Address - Country:US
Mailing Address - Phone:941-758-1636
Mailing Address - Fax:941-894-6224
Practice Address - Street 1:3653 CORTEZ RD W
Practice Address - Street 2:SUITE 110 H
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3168
Practice Address - Country:US
Practice Address - Phone:941-758-1636
Practice Address - Fax:941-894-6224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0004477465OtherAETNA
FL01128702OtherAMERIGROUP
FL001713800Medicaid
FL257481OtherMHN
FLUAW065769OtherVALUE OPTIONS/MILITARY ONE SOURCE
FL0004477465OtherAETNA