Healthcare Provider Details

I. General information

NPI: 1033760186
Provider Name (Legal Business Name): CHAYA LIEBA KOBERNICK PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13523 78TH RD
FLUSHING NY
11367-3239
US

IV. Provider business mailing address

13523 78TH RD
FLUSHING NY
11367-3239
US

V. Phone/Fax

Practice location:
  • Phone: 917-494-3708
  • Fax:
Mailing address:
  • Phone: 917-494-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP102639
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number023935
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: