Basic Information
| Provider Information | |||||||||
| NPI: | 1346203551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVOL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHRYN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 W 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464263876 | ||||||||
| FaxNumber: | 2123055445 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 W 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464263876 | ||||||||
| FaxNumber: | 2123055445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 02/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 012994 | NY | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.