Provider Demographics
NPI:1770941767
Name:MARTHA BRICENO, LCSW FAMILY PSYCHOTHERAPY PLLC
Entity type:Organization
Organization Name:MARTHA BRICENO, LCSW FAMILY PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRICENO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:646-753-4301
Mailing Address - Street 1:3330 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-7055
Mailing Address - Country:US
Mailing Address - Phone:646-753-4301
Mailing Address - Fax:
Practice Address - Street 1:244 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-1204
Practice Address - Country:US
Practice Address - Phone:646-753-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0825671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY49H68EQ111OtherMEDICARE
NY03471634Medicaid