Provider Demographics
NPI:1891862280
Name:MARGOLIS, IRENE SUSAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:SUSAN
Last Name:MARGOLIS
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 1:13 POTOMAC COURT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1661
Mailing Address - Country:US
Mailing Address - Phone:631-331-9688
Mailing Address - Fax:631-331-3020
Practice Address - Street 1:13 POTOMAC COURT
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1661
Practice Address - Country:US
Practice Address - Phone:631-331-9688
Practice Address - Fax:631-331-3020
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04595611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY61022401554Medicaid
NYN79792Medicare ID - Type Unspecified