Provider Demographics
NPI:1083725675
Name:CENTRONE, MARY A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:CENTRONE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 SE 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1207
Mailing Address - Country:US
Mailing Address - Phone:954-675-6892
Mailing Address - Fax:954-793-4651
Practice Address - Street 1:619 SE 9TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1207
Practice Address - Country:US
Practice Address - Phone:954-675-6892
Practice Address - Fax:954-793-4651
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5407ZMedicare ID - Type UnspecifiedPSYCHOLOGIST