Basic Information
| Provider Information | |||||||||
| NPI: | 1396922704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENNIN | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 LINTON ST | ||||||||
| Address2: | |||||||||
| City: | SELKIRK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121589740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184396767 | ||||||||
| FaxNumber: | 5184396767 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 ROCKEFELLER RD | ||||||||
| Address2: | |||||||||
| City: | DELMAR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120542221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184398116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 013925-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103TA0700X | 013925-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
No ID Information.