Provider Demographics
NPI:1497796882
Name:MARRAZO, MARTIN JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOSEPH
Last Name:MARRAZO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 224
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2490
Mailing Address - Country:US
Mailing Address - Phone:518-785-3614
Mailing Address - Fax:518-785-3615
Practice Address - Street 1:713 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 224
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2490
Practice Address - Country:US
Practice Address - Phone:518-785-3614
Practice Address - Fax:518-785-3615
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4777-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB7526Medicare ID - Type Unspecified