Provider Demographics
NPI:1528108651
Name:VAN DER JAGT, MARY ANN (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:VAN DER JAGT
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BRADY RD
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-9504
Mailing Address - Country:US
Mailing Address - Phone:845-325-3960
Mailing Address - Fax:
Practice Address - Street 1:28 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1639
Practice Address - Country:US
Practice Address - Phone:845-986-3766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-074382-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical