Healthcare Provider Details

I. General information

NPI: 1982994141
Provider Name (Legal Business Name): ILANA KUSTANOWITZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 HENRY HUDSON PKWY APT 6A
BRONX NY
10463-1535
US

IV. Provider business mailing address

3755 HENRY HUDSON PKWY APT 6A
BRONX NY
10463-1535
US

V. Phone/Fax

Practice location:
  • Phone: 347-920-3036
  • Fax:
Mailing address:
  • Phone: 347-920-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number018417
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: