Provider Demographics
NPI:1700049665
Name:DZEMBO, DANIEL MARK (MSW LCSW R)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:DZEMBO
Suffix:
Gender:M
Credentials:MSW LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9206
Mailing Address - Country:US
Mailing Address - Phone:518-456-5056
Mailing Address - Fax:
Practice Address - Street 1:2280 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084-9206
Practice Address - Country:US
Practice Address - Phone:518-456-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042105 11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical