Provider Demographics
NPI:1891280285
Name:WEISS, MARTIN (MSED, BCBA LP)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:MSED, BCBA LP
Other - Prefix:MR
Other - First Name:SHLOMO
Other - Middle Name:MORDECHAI
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1426 46TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2632
Mailing Address - Country:US
Mailing Address - Phone:347-988-5772
Mailing Address - Fax:
Practice Address - Street 1:4404 14TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2104
Practice Address - Country:US
Practice Address - Phone:347-988-5772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBACB351913103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY114186579Medicaid