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General NPI Number Information
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NPI Number | 1528108651
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Entity Type | Individual
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Provider Name | MARY ANN VAN DER JAGT LCSW-R
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Gender | Female
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 28 RAILROAD AVE
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City | WARWICK
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State | NY
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Zip | 10990-1639
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Country | US
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Telephone | 845-986-3766
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Fax |
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Provider Business Mailing Address
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Address Line | 302 BRADY RD
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City | SACKETS HARBOR
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State | NY
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Zip | 13685-9504
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Country | US
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Telephone | 845-325-3960
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | R-074382-1
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License Number State | NY
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