Healthcare Provider Details

I. General information

NPI: 1902992902
Provider Name (Legal Business Name): MARY POWELL LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 BRYSON AVE
STATEN ISLAND NY
10314-1923
US

IV. Provider business mailing address

296 CHESTERTON AVE 2ND FLOOR
STATEN ISLAND NY
10306-4402
US

V. Phone/Fax

Practice location:
  • Phone: 347-628-0850
  • Fax: 718-979-5958
Mailing address:
  • Phone: 347-628-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072324
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: