Provider Demographics
NPI:1639137466
Name:FLANZRAICH, MARK JAY (DSW, LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JAY
Last Name:FLANZRAICH
Suffix:
Gender:M
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 DALEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3604
Mailing Address - Country:US
Mailing Address - Phone:516-741-6166
Mailing Address - Fax:516-741-6166
Practice Address - Street 1:34 DALEY ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-3604
Practice Address - Country:US
Practice Address - Phone:516-741-6166
Practice Address - Fax:516-741-6166
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P0225811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN98391Medicare ID - Type Unspecified