Healthcare Provider Details

I. General information

NPI: 1790426831
Provider Name (Legal Business Name): MARY SWINSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 KAPPOCK ST APT 7C
BRONX NY
10463-6429
US

IV. Provider business mailing address

555 KAPPOCK ST APT 7C
BRONX NY
10463-6429
US

V. Phone/Fax

Practice location:
  • Phone: 336-830-3041
  • Fax:
Mailing address:
  • Phone: 336-830-3041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104959
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098260
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: