Provider Demographics
NPI:1679192405
Name:REYNOSO, MARILYN (LMSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ELMWOOD TER APT B
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1764
Mailing Address - Country:US
Mailing Address - Phone:646-398-0766
Mailing Address - Fax:
Practice Address - Street 1:429 E 148TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4128
Practice Address - Country:US
Practice Address - Phone:718-585-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NY109158104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No252Y00000XAgenciesEarly Intervention Provider Agency