Provider Demographics
NPI:1568008506
Name:WLAZLO, MARTA
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:WLAZLO
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 1:5841 79TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5311
Mailing Address - Country:US
Mailing Address - Phone:646-474-3074
Mailing Address - Fax:
Practice Address - Street 1:6317B METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-1606
Practice Address - Country:US
Practice Address - Phone:646-818-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health