Provider Demographics
NPI:1407416118
Name:KENNY CORRON, MARY M (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:KENNY CORRON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MARGARET
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:244 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-1810
Mailing Address - Country:US
Mailing Address - Phone:631-686-5856
Mailing Address - Fax:
Practice Address - Street 1:83 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8305
Practice Address - Country:US
Practice Address - Phone:631-219-4975
Practice Address - Fax:631-982-7274
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0683511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical