MEDICARE: MARLY REDJINA BRISA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1871301580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLY REDJINA BRISA

Provider Business Mailing Address
First Line	:	35-24 83RD STREET, 3RD FLOOR
Second Line	:
City	:	JACKSON HEIGHT
State	:	NY
Zip	:	11372-1137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	35-24 83RD STREET, 3RD FLOOR
Second Line	:
City	:	JACKSON HEIGHT
State	:	NY
Zip	:	11372
Country	:	US
Telephone Number	:	718-639-0700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2024
Last Update Date	:	12/27/2024

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Directions to “ MARLY REDJINA BRISA ” Practice Location

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