Provider Demographics
NPI:1104706977
Name:VARGAS, MARLENNY
Entity type:Individual
Prefix:
First Name:MARLENNY
Middle Name:
Last Name:VARGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARLENNY
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1512 BEACH AVE APT BSMT
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-6320
Mailing Address - Country:US
Mailing Address - Phone:347-316-1459
Mailing Address - Fax:
Practice Address - Street 1:114 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3833
Practice Address - Country:US
Practice Address - Phone:516-868-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010568101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty