Individual
MARY TEN BROECH DURSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LICENSED PSYCHOLOGIS
Contact information
Practice address
359 S MOUNTAIN BLVD, SUITE C2, MOUTAINTOP, PA 18707
(570) 403-5080
(570) 403-5079
Mailing address
HC 88 BOX 434, POCONO LAKE, PA 18347-9512
(570) 646-0870
(570) 403-5079
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
PS006873L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0016193400002
—
PA
01
—
080953
FIRST PRIORITY HLTH
PA
01
—
2056962
CIGNA
PA
Enumeration date
05/09/2006
Last updated
04/09/2014
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