Provider Demographics
NPI:1851455760
Name:BLONDELL, MARTIN JOSEPH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:JOSEPH
Last Name:BLONDELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 AMBOY RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2414
Mailing Address - Country:US
Mailing Address - Phone:718-967-4919
Mailing Address - Fax:718-317-8898
Practice Address - Street 1:3974 AMBOY RD
Practice Address - Street 2:SUITE 306
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2414
Practice Address - Country:US
Practice Address - Phone:718-967-4919
Practice Address - Fax:718-317-8898
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0326791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN71731Medicare ID - Type Unspecified