Provider Demographics
NPI:1982833927
Name:LEQUERICA, MARTHA (PHD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:LEQUERICA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-1801
Mailing Address - Country:US
Mailing Address - Phone:800-725-6280
Mailing Address - Fax:
Practice Address - Street 1:1 OLD COUNTRY RD
Practice Address - Street 2:SUITE 271
Practice Address - City:CARLE PLACE
Practice Address - State:NY
Practice Address - Zip Code:11514-1801
Practice Address - Country:US
Practice Address - Phone:800-725-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007616103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist