Provider Demographics
NPI:1295885739
Name:LELAH, MARK J (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LELAH
Suffix:
Gender:M
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:PO BOX 1562
Mailing Address - Street 2:99 DEPOT STREET
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-1562
Mailing Address - Country:US
Mailing Address - Phone:845-744-5147
Mailing Address - Fax:845-744-8906
Practice Address - Street 1:99 DEPOT STREET
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-1562
Practice Address - Country:US
Practice Address - Phone:845-744-5147
Practice Address - Fax:845-744-8906
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024847101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health