Provider Demographics
NPI:1679757850
Name:MCCORQUODALE, MARY ANN (CGBA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:MCCORQUODALE
Suffix:
Gender:F
Credentials:CGBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S STATE STREET
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-468-9347
Mailing Address - Fax:707-468-5234
Practice Address - Street 1:301 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4906
Practice Address - Country:US
Practice Address - Phone:707-468-9347
Practice Address - Fax:707-468-5234
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker