Healthcare Provider Details

I. General information

NPI: 1144281833
Provider Name (Legal Business Name): MARTIN WAKESBERG MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SARATOGA RD
GLENVILLE NY
12302-7100
US

IV. Provider business mailing address

1 BRIERWOOD CT
BURNT HILLS NY
12027-9451
US

V. Phone/Fax

Practice location:
  • Phone: 518-399-0637
  • Fax: 518-399-7195
Mailing address:
  • Phone: 518-399-6741
  • Fax: 518-399-7195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR017417-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: