Healthcare Provider Details

I. General information

NPI: 1841577004
Provider Name (Legal Business Name): MARK S. CLOSSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FRANKLIN AVE STE 200
GARDEN CITY NY
11530-5760
US

IV. Provider business mailing address

601 FRANKLIN AVE STE 200
GARDEN CITY NY
11530-5760
US

V. Phone/Fax

Practice location:
  • Phone: 516-669-0135
  • Fax: 631-754-1642
Mailing address:
  • Phone: 516-669-0135
  • Fax: 631-754-1642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019356
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: