Provider Demographics
NPI:1285911701
Name:PROVENZANO, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:HARISSIS-PROVENZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1867 STATE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9303
Mailing Address - Country:US
Mailing Address - Phone:585-872-4561
Mailing Address - Fax:
Practice Address - Street 1:119 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-3559
Practice Address - Country:US
Practice Address - Phone:585-216-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist