=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932651833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARCUS MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2016
-----------------------------------------------------
Last Update Date | 10/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 SOUTHDOWN RD SUITE 2
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-425-2650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 SOUTHDOWN RD SUITE 2
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-425-2650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | RO26671
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------