Provider Demographics
NPI:1487703542
Name:STREETE, MARY E (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:STREETE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 COLONIAL RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5160
Mailing Address - Country:US
Mailing Address - Phone:901-681-0851
Mailing Address - Fax:901-681-0872
Practice Address - Street 1:670 COLONIAL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-5160
Practice Address - Country:US
Practice Address - Phone:901-681-0851
Practice Address - Fax:901-681-0872
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNIP4901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3690381Medicare ID - Type Unspecified