Provider Demographics
NPI:1861821274
Name:SONG, MARCIA (LAC)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 COMMON ST
Mailing Address - Street 2:APT #11
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4733
Mailing Address - Country:US
Mailing Address - Phone:347-610-0072
Mailing Address - Fax:
Practice Address - Street 1:19 W 21ST ST
Practice Address - Street 2:SUITE 904
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6805
Practice Address - Country:US
Practice Address - Phone:347-610-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005263171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist