Provider Demographics
NPI:1336254895
Name:GUADAGNO, MARYELLEN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:GUADAGNO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:PASTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1289 ROUTE 38 WEST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036
Mailing Address - Country:US
Mailing Address - Phone:609-261-3330
Mailing Address - Fax:609-265-1064
Practice Address - Street 1:1289 ROUTE 38 WEST
Practice Address - Street 2:SUITE 101
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036
Practice Address - Country:US
Practice Address - Phone:609-267-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0724871041C0700X
NJ44SC054434001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426034419OtherFIDELIS PROVIDER NUMBER
NYN45S81Medicare ID - Type Unspecified