Provider Demographics
NPI:1053756551
Name:MENTOR, MARY-ANTONETTE G (LCSW)
Entity type:Individual
Prefix:
First Name:MARY-ANTONETTE
Middle Name:G
Last Name:MENTOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MANHATTAN AVE APT 7L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2667
Mailing Address - Country:US
Mailing Address - Phone:917-833-8084
Mailing Address - Fax:
Practice Address - Street 1:220 MANHATTAN AVE APT 7L
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2667
Practice Address - Country:US
Practice Address - Phone:917-833-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0730861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical