Provider Demographics
NPI:1659396075
Name:VELKY-REGER, MARLA S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:S
Last Name:VELKY-REGER
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 1:662 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2624
Mailing Address - Country:US
Mailing Address - Phone:315-243-3146
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA2529Medicare ID - Type Unspecified