Provider Demographics
NPI:1144303090
Name:MASSA, MARILYNN MAGALY (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARILYNN
Middle Name:MAGALY
Last Name:MASSA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 78TH ST
Mailing Address - Street 2:#B21
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4750
Mailing Address - Country:US
Mailing Address - Phone:917-589-7796
Mailing Address - Fax:
Practice Address - Street 1:141 E 33RD ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4606
Practice Address - Country:US
Practice Address - Phone:917-589-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058394-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR058394-1OtherSOCIAL WORKER LICENSE NUM