Provider Demographics
NPI:1649492935
Name:NATISHYN, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:NATISHYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 237
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5378
Mailing Address - Country:US
Mailing Address - Phone:407-830-0417
Mailing Address - Fax:407-830-1830
Practice Address - Street 1:300 WILSHIRE BLVD
Practice Address - Street 2:SUITE 237
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5378
Practice Address - Country:US
Practice Address - Phone:407-830-0417
Practice Address - Fax:407-830-1830
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 60621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical