Basic Information
| Provider Information | |||||||||
| NPI: | 1295774743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRY | ||||||||
| FirstName: | MARYANNE | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROGAN | ||||||||
| OtherFirstName: | MARYANNE | ||||||||
| OtherMiddleName: | THERESA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 142 WEST END AVENUE | ||||||||
| Address2: | #28 W | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100236123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465051553 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19 W 34TH ST | ||||||||
| Address2: | #PH | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465051553 | ||||||||
| FaxNumber: | 7188375676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 070783 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | R070783 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.