Provider Demographics
NPI:1154461879
Name:BLANK, MARCIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1502
Mailing Address - Country:US
Mailing Address - Phone:516-621-4278
Mailing Address - Fax:516-621-4275
Practice Address - Street 1:46 BARBERRY LN
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1502
Practice Address - Country:US
Practice Address - Phone:516-621-4278
Practice Address - Fax:516-621-4275
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR13959104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7493669OtherEMPIRE
NY7493669OtherEMPIRE