Provider Demographics
NPI:1902939473
Name:MACCONNELL, MARY MARGARET (LCSW BCD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARGARET
Last Name:MACCONNELL
Suffix:
Gender:F
Credentials:LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13364 BEACH BLVD UNIT 1032
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0272
Mailing Address - Country:US
Mailing Address - Phone:631-834-5714
Mailing Address - Fax:
Practice Address - Street 1:13364 BEACH BLVD UNIT 1032
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0272
Practice Address - Country:US
Practice Address - Phone:631-834-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0404101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY164770OtherPIN
NYNT2091Medicare PIN