Provider Demographics
NPI:1063774909
Name:BLANK, MARC (MS, MS, EDM)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:MS, MS, EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BALTUSROL DR
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-9325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 BALTUSROL DR
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-9325
Practice Address - Country:US
Practice Address - Phone:732-319-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510128931174400000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No174400000XOther Service ProvidersSpecialist