Healthcare Provider Details

I. General information

NPI: 1073601662
Provider Name (Legal Business Name): MARY A MCCARTHY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 WASHINGTON ST
MONTPELIER ID
83254-5091
US

IV. Provider business mailing address

1011 WASHINGTON ST
MONTPELIER ID
83254-5091
US

V. Phone/Fax

Practice location:
  • Phone: 307-413-5803
  • Fax:
Mailing address:
  • Phone: 307-413-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number489
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSWS1104
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10144643-3501
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1104
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1101
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number125
License Number StateGU
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36300
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: