Provider Demographics
NPI:1194546788
Name:BALCERAK, MARY IRENE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:IRENE
Last Name:BALCERAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 HARPENDING AVE
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:NY
Mailing Address - Zip Code:14837-1150
Mailing Address - Country:US
Mailing Address - Phone:607-678-0014
Mailing Address - Fax:
Practice Address - Street 1:620 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2319
Practice Address - Country:US
Practice Address - Phone:315-426-3985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433624323P00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility