Provider Demographics
NPI:1689959223
Name:DENNIS, MARLENE A
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:A
Last Name:DENNIS
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 1:10325 168TH PL
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-1727
Mailing Address - Country:US
Mailing Address - Phone:917-288-8736
Mailing Address - Fax:
Practice Address - Street 1:135 W 50TH ST # W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10020-1201
Practice Address - Country:US
Practice Address - Phone:212-304-1430
Practice Address - Fax:718-365-2777
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320800000X320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness