Provider Demographics
NPI:1902992902
Name:POWELL, MARY (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:POWELL
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 1:296 CHESTERTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4402
Mailing Address - Country:US
Mailing Address - Phone:347-628-0850
Mailing Address - Fax:
Practice Address - Street 1:286 BRYSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1923
Practice Address - Country:US
Practice Address - Phone:347-628-0850
Practice Address - Fax:718-979-5958
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0723241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNF4871Medicare ID - Type Unspecified