Healthcare Provider Details

I. General information

NPI: 1174997720
Provider Name (Legal Business Name): MARY BETH MIJARES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 ADAM CLAYTON POWELL JR BLVD
NEW YORK NY
10027
US

IV. Provider business mailing address

590 AVENUE OF THE AMERICAS
NEW YORK NY
10011-2022
US

V. Phone/Fax

Practice location:
  • Phone: 212-633-9300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP03642
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: