Healthcare Provider Details

I. General information

NPI: 1598787095
Provider Name (Legal Business Name): MARK DIMARTINO L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

IV. Provider business mailing address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

V. Phone/Fax

Practice location:
  • Phone: 518-952-8335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number026080
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: