Provider Demographics
NPI:1518595875
Name:TODD, MARY ELISABETH
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELISABETH
Last Name:TODD
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 1:265 E BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-3712
Mailing Address - Country:US
Mailing Address - Phone:718-583-7589
Mailing Address - Fax:718-583-7923
Practice Address - Street 1:265 E BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-3712
Practice Address - Country:US
Practice Address - Phone:718-583-7589
Practice Address - Fax:718-583-7923
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045517103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty