Provider Demographics
NPI:1295141364
Name:CONCHA, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:CONCHA
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 1:235 WADSWORTH AVE
Mailing Address - Street 2:4A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3810
Mailing Address - Country:US
Mailing Address - Phone:646-584-8268
Mailing Address - Fax:
Practice Address - Street 1:4277 65TH PL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5054
Practice Address - Country:US
Practice Address - Phone:718-429-2000
Practice Address - Fax:718-334-0057
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency