Healthcare Provider Details

I. General information

NPI: 1245220169
Provider Name (Legal Business Name): MIRIAM JOHN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2005
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WASHINGTON SQ APT 6A
LARCHMONT NY
10538-2019
US

IV. Provider business mailing address

2 WASHINGTON SQ APT 6A
LARCHMONT NY
10538-2019
US

V. Phone/Fax

Practice location:
  • Phone: 914-833-1125
  • Fax: 914-833-7873
Mailing address:
  • Phone: 914-833-1125
  • Fax: 914-833-7873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: