Provider Demographics
NPI:1306313614
Name:MONGE, MARIA MARCELA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MARCELA
Last Name:MONGE
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 1:724 DEKALB AVE APT 4G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4610
Mailing Address - Country:US
Mailing Address - Phone:831-419-7512
Mailing Address - Fax:
Practice Address - Street 1:102 PILLING ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1610
Practice Address - Country:US
Practice Address - Phone:718-602-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNF37476HMedicaid