Provider Demographics
NPI:1144281833
Name:WAKESBERG, MARTIN (MSW)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:WAKESBERG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRIERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BURNT HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:12027-9451
Mailing Address - Country:US
Mailing Address - Phone:518-399-6741
Mailing Address - Fax:518-399-7195
Practice Address - Street 1:113 SARATOGA RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-7100
Practice Address - Country:US
Practice Address - Phone:518-399-0637
Practice Address - Fax:518-399-7195
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR017417-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0540Medicare ID - Type Unspecified
NYQ20214Medicare UPIN