Healthcare Provider Details

I. General information

NPI: 1730833997
Provider Name (Legal Business Name): MARY COWEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY DURRETT LCSW

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MARK TWAIN CT
MOUNT HOLLY NC
28120-1596
US

IV. Provider business mailing address

104 MARK TWAIN CT
MOUNT HOLLY NC
28120-1596
US

V. Phone/Fax

Practice location:
  • Phone: 191-878-1937
  • Fax:
Mailing address:
  • Phone: 918-781-9379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-008100
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: