Healthcare Provider Details

I. General information

NPI: 1730722661
Provider Name (Legal Business Name): MARCUS MUAMBA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 GRAND ST FL 2
NEW YORK NY
10002-4800
US

IV. Provider business mailing address

229 W 111TH ST APT 3
NEW YORK NY
10026-4165
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-1970
  • Fax:
Mailing address:
  • Phone: 917-586-4937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number063466
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: