Provider Demographics
NPI:1487237301
Name:ADAMS, MARYELLEN
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:ADAMS
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 1:211 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1827
Mailing Address - Country:US
Mailing Address - Phone:631-327-9551
Mailing Address - Fax:
Practice Address - Street 1:107 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2337
Practice Address - Country:US
Practice Address - Phone:631-666-1615
Practice Address - Fax:631-666-1709
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011181-01101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty