Provider Demographics
NPI:1053343855
Name:SIDERIS, MARSHA (LCSW)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:SIDERIS
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 1:2155 66TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3923
Mailing Address - Country:US
Mailing Address - Phone:917-757-3162
Mailing Address - Fax:
Practice Address - Street 1:2155 66TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3923
Practice Address - Country:US
Practice Address - Phone:917-757-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP062079-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMSON214R10Medicare ID - Type UnspecifiedEMPIRE MEDICARE PROVIDER