Healthcare Provider Details

I. General information

NPI: 1659303204
Provider Name (Legal Business Name): MYRA MARKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 FOREST AVE
STATEN ISLAND NY
10310-2405
US

IV. Provider business mailing address

164 ROLLING HILL GRN
STATEN ISLAND NY
10312-1803
US

V. Phone/Fax

Practice location:
  • Phone: 718-966-3908
  • Fax: 718-983-0348
Mailing address:
  • Phone: 917-952-0637
  • Fax: 718-983-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR047036
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: