Healthcare Provider Details

I. General information

NPI: 1891292660
Provider Name (Legal Business Name): MANHASSET PSYCHOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PLANDOME RD
MANHASSET NY
11030-2303
US

IV. Provider business mailing address

75 PLANDOME RD
MANHASSET NY
11030-2303
US

V. Phone/Fax

Practice location:
  • Phone: 516-304-5700
  • Fax: 516-304-5702
Mailing address:
  • Phone: 516-304-5700
  • Fax: 516-304-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number006325-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number006325-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number006325-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number006325-1
License Number StateNY

VIII. Authorized Official

Name: MARC JANOSON
Title or Position: PRESIDENT
Credential:
Phone: 516-304-5700