Healthcare Provider Details

I. General information

NPI: 1265442495
Provider Name (Legal Business Name): MARY BETH MCDONOUGH CSWR-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 CANISTEO ST
HORNELL NY
14843-9768
US

IV. Provider business mailing address

111 E 14TH ST
ELMIRA HEIGHTS NY
14903-1303
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-3580
  • Fax: 607-324-3998
Mailing address:
  • Phone: 607-734-9539
  • Fax: 607-734-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR045595-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: