Provider Demographics
NPI:1659303204
Name:MARKS, MYRA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:
Last Name:MARKS
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 1:164 ROLLING HILL GRN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1803
Mailing Address - Country:US
Mailing Address - Phone:917-952-0637
Mailing Address - Fax:718-983-0348
Practice Address - Street 1:1076 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2405
Practice Address - Country:US
Practice Address - Phone:718-966-3908
Practice Address - Fax:718-983-0348
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047036104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN280X1Medicare ID - Type UnspecifiedLCSW