MEDICARE: MARY ELLEN LOUREY LCSW-R

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	1041C0700X	Clinical Social Worker	076608	NY

General Provider Information

NPI Number	:	1629093232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN LOUREY LCSW-R

Provider Business Mailing Address
First Line	:	PO BOX 275
Second Line	:
City	:	JACKSONVILLE
State	:	NY
Zip	:	14854-0275
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5165 JACKSONVILLE RD
Second Line	:
City	:	TRUMANSBURG
State	:	NY
Zip	:	14886-9001
Country	:	US
Telephone Number	:	607-793-7127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	02/02/2023

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