Healthcare Provider Details

I. General information

NPI: 1689989345
Provider Name (Legal Business Name): MARY ANN YACONIS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 OLD NISKAYUNA RD
LATHAM NY
12110-1569
US

IV. Provider business mailing address

458 OLD NISKAYUNA RD
LATHAM NY
12110-1569
US

V. Phone/Fax

Practice location:
  • Phone: 518-867-9118
  • Fax:
Mailing address:
  • Phone: 518-867-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number004024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: