Provider Demographics
NPI:1144327735
Name:DAIGNEAULT, MARY (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:DAIGNEAULT
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 1:30 COLE LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-7217
Mailing Address - Country:US
Mailing Address - Phone:518-424-6097
Mailing Address - Fax:518-629-0171
Practice Address - Street 1:596 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4024
Practice Address - Country:US
Practice Address - Phone:518-424-6097
Practice Address - Fax:518-783-4793
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR032932-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01667858Medicaid
NY000400090001OtherBLUE SHIELD OF NENY
NY7481509OtherVALUE OPTIONS EMPRIE PLAN
NY000400090001OtherBLUE SHIELD OF NENY