Provider Demographics
NPI:1063712404
Name:TODD, MARY BURGESS (MA, PC, CFC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BURGESS
Last Name:TODD
Suffix:
Gender:F
Credentials:MA, PC, CFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 GLENVIEW TERRACE
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883
Mailing Address - Country:US
Mailing Address - Phone:419-934-0330
Mailing Address - Fax:419-448-4095
Practice Address - Street 1:777 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-3325
Practice Address - Country:US
Practice Address - Phone:419-448-4094
Practice Address - Fax:419-448-4095
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-0900022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional