Healthcare Provider Details

I. General information

NPI: 1891993549
Provider Name (Legal Business Name): SUSAN E REPETTO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2007
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 7TH ST STE 300
GARDEN CITY NY
11530-5747
US

IV. Provider business mailing address

233 7TH ST STE 300
GARDEN CITY NY
11530-5747
US

V. Phone/Fax

Practice location:
  • Phone: 212-254-2155
  • Fax:
Mailing address:
  • Phone: 212-254-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016082
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: