Provider Demographics
NPI:1285963603
Name:WINOGRAD, MARIE G
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:G
Last Name:WINOGRAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8479 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2207
Mailing Address - Country:US
Mailing Address - Phone:718-847-8434
Mailing Address - Fax:
Practice Address - Street 1:8479 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-2207
Practice Address - Country:US
Practice Address - Phone:718-847-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005288320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities