Healthcare Provider Details

I. General information

NPI: 1306086533
Provider Name (Legal Business Name): WANDA I MARQUEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 NAGLE AVE APT 14B NEW YORK
NEW YORK NY
10034-6024
US

IV. Provider business mailing address

52 GLENWOOD DR N
BERGENFIELD NJ
07621-3346
US

V. Phone/Fax

Practice location:
  • Phone: 646-281-2592
  • Fax:
Mailing address:
  • Phone: 646-281-2592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number059454-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075249-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1742682
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: