Healthcare Provider Details

I. General information

NPI: 1013554062
Provider Name (Legal Business Name): MARISSA GAYLE FRUCHTER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 DEAN ST STE 226
BROOKLYN NY
11238-3383
US

IV. Provider business mailing address

1000 DEAN ST STE 226
BROOKLYN NY
11238-3383
US

V. Phone/Fax

Practice location:
  • Phone: 347-669-9792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022923
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: