Healthcare Provider Details

I. General information

NPI: 1275208480
Provider Name (Legal Business Name): MARY CLOHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 GRAND CONCOURSE
BRONX NY
10457-8400
US

IV. Provider business mailing address

112 KINGSTON AVE # 2F
BROOKLYN NY
11213-1514
US

V. Phone/Fax

Practice location:
  • Phone: 718-931-4045
  • Fax:
Mailing address:
  • Phone: 864-915-1328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: