1770941767 NPI number — MARTHA BRICENO, LCSW FAMILY PSYCHOTHERAPY PLLC

Table of content: (NPI 1770941767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770941767 NPI number — MARTHA BRICENO, LCSW FAMILY PSYCHOTHERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTHA BRICENO, LCSW FAMILY PSYCHOTHERAPY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770941767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 STONEHENGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-7055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-753-4301
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 GRAHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11206-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-753-4301
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRICENO
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CLINICIAN
Authorized Official Telephone Number:
646-753-4301

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  082567 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49H68EQ111 . This is a "MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03471634 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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