Provider Demographics
NPI:1013471564
Name:DELOACHE, MARIE ELCY
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ELCY
Last Name:DELOACHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 E 54TH ST APT 6O
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2430
Mailing Address - Country:US
Mailing Address - Phone:718-690-6509
Mailing Address - Fax:
Practice Address - Street 1:1165 E 54TH ST APT 6O
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2430
Practice Address - Country:US
Practice Address - Phone:718-690-6509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1292901252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0675460013OtherHSPO
PA0675460013OtherHPSO