Provider Demographics
NPI:1508064551
Name:HERTZOG, MARCIA H (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:H
Last Name:HERTZOG
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 1:361 W.WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3332
Mailing Address - Country:US
Mailing Address - Phone:607-737-4063
Mailing Address - Fax:607-734-2019
Practice Address - Street 1:361 W WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-2519
Practice Address - Country:US
Practice Address - Phone:607-737-4063
Practice Address - Fax:607-734-2019
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR028240-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR88702Medicare UPIN
NYDD5277Medicare PIN