Provider Demographics
NPI:1760503601
Name:IPPOLITO, MARILYN H (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:H
Last Name:IPPOLITO
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 1:1818 NEWKIRK AVE
Mailing Address - Street 2:APT 6D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-7359
Mailing Address - Country:US
Mailing Address - Phone:347-350-8464
Mailing Address - Fax:
Practice Address - Street 1:54 MONTGOMERY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-2358
Practice Address - Country:US
Practice Address - Phone:347-415-3619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR018093-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM571587OtherVALUOPTIONS
NY0124339OtherGHI
NM571587OtherVALUOPTIONS