Healthcare Provider Details

I. General information

NPI: 1164478871
Provider Name (Legal Business Name): MIRIAM EISDORFER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MIDDLETON ST
BROOKLYN NY
11206-5415
US

IV. Provider business mailing address

1416 59TH ST
BROOKLYN NY
11219-5016
US

V. Phone/Fax

Practice location:
  • Phone: 718-875-6900
  • Fax: 718-875-3282
Mailing address:
  • Phone: 718-851-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number012869
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: