Healthcare Provider Details

I. General information

NPI: 1861154395
Provider Name (Legal Business Name): ALEC JAY MIODOWNIK PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: AVI MIODOWNIK PSYD

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

800 POLY PL
BROOKLYN NY
11209-7104
US

V. Phone/Fax

Practice location:
  • Phone: 718-836-6600
  • Fax:
Mailing address:
  • Phone: 718-836-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number024540
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: