Provider Demographics
NPI:1750943569
Name:CHASE, PETAGAYE MARSHALEE (MS,SPECIAL EDUCATION)
Entity type:Individual
Prefix:MRS
First Name:PETAGAYE
Middle Name:MARSHALEE
Last Name:CHASE
Suffix:
Gender:F
Credentials:MS,SPECIAL EDUCATION
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 360070
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-0070
Mailing Address - Country:US
Mailing Address - Phone:631-805-9525
Mailing Address - Fax:
Practice Address - Street 1:139 NEWPORT ST APT 2F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5390
Practice Address - Country:US
Practice Address - Phone:631-805-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1313099291174400000X
NY1313092191174400000X
NY1312574191174400000X
NY1313962191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY927711186OtherDRIVER'S LICENCE