Provider Demographics
NPI:1538226667
Name:WEBER, MARY-JO D (NP)
Entity type:Individual
Prefix:MS
First Name:MARY-JO
Middle Name:D
Last Name:WEBER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-2315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 CROSS RIVER RD
Practice Address - Street 2:
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536-3549
Practice Address - Country:US
Practice Address - Phone:914-763-8151
Practice Address - Fax:877-810-1175
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400379363LP0808X
CT001681364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY96N951Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER