Healthcare Provider Details

I. General information

NPI: 1851362743
Provider Name (Legal Business Name): RALPH KIRSCHNER MARCELLUS MSW, LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG. T-2228, FT DRUM N.Y.
FORT DRUM NY
13602-5004
US

IV. Provider business mailing address

24384 NYS RTE 12
WATERTOWN NY
13601-5012
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-8801
  • Fax: 315-772-4097
Mailing address:
  • Phone: 315-772-9807
  • Fax: 315-788-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR030329-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: