Provider Demographics
NPI:1124575683
Name:ETIENNE, MARLYNE
Entity Type:Individual
Prefix:
First Name:MARLYNE
Middle Name:
Last Name:ETIENNE
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 1:7000 AUSTIN STREET SUITE #200
Mailing Address - Street 2:
Mailing Address - City:FORREST HILLS,
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-762-7633
Mailing Address - Fax:718-886-8694
Practice Address - Street 1:7000 AUSTIN ST STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4739
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:718-886-8694
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1051808161252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency