Provider Demographics
NPI:1396801486
Name:BLANK, MARSHA (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:
Last Name:BLANK
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 1:279 WINDSOR PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1260
Mailing Address - Country:US
Mailing Address - Phone:718-965-2817
Mailing Address - Fax:718-965-2817
Practice Address - Street 1:279 WINDSOR PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-1260
Practice Address - Country:US
Practice Address - Phone:718-965-2817
Practice Address - Fax:718-965-2817
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040432-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1293158OtherOXFORD
NY0047223OtherGHI
NY298933OtherHEALTH NET
NY143875OtherVALUE OPTIONS