MEDICARE: MARY MARIE'S MISSION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1417219429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY MARIE'S MISSION

Provider Business Mailing Address
First Line	:	1503 ATLANTIC AVE APT 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-1071
Country	:	US
Telephone Number	:	678-523-4437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1503 ATLANTIC AVE APT 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-1071
Country	:	US
Telephone Number	:	678-523-4437
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL EDUCATION
Name	:	MS. KATRINA THOMAS
Credential	:	MS ED
Telephone Number	:	678-523-4437

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	06/14/2012

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