Provider Demographics
NPI:1104325695
Name:MARY MITCHELL HADDAD PMHNP LLC
Entity type:Organization
Organization Name:MARY MITCHELL HADDAD PMHNP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, PMHNP
Authorized Official - Phone:203-952-7571
Mailing Address - Street 1:960 GREEN CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-1736
Mailing Address - Country:US
Mailing Address - Phone:203-952-7571
Mailing Address - Fax:
Practice Address - Street 1:211 E 43RD ST RM 1305
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4779
Practice Address - Country:US
Practice Address - Phone:203-952-7571
Practice Address - Fax:212-642-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402319-1261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health