Healthcare Provider Details

I. General information

NPI: 1689497554
Provider Name (Legal Business Name): BRUCE PROFSKY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 13TH AVE
BROOKLYN NY
11219-1389
US

IV. Provider business mailing address

3606 AVENUE S
BROOKLYN NY
11234-4830
US

V. Phone/Fax

Practice location:
  • Phone: 718-400-9988
  • Fax:
Mailing address:
  • Phone: 718-419-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405636
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: