Healthcare Provider Details

I. General information

NPI: 1598750853
Provider Name (Legal Business Name): JUDITH BARBARA ROSENBLUM PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 BROADWAY STE 200
MASSAPEQUA NY
11758-5031
US

IV. Provider business mailing address

288 BIRCHWOOD RD
MEDFORD NY
11763-1239
US

V. Phone/Fax

Practice location:
  • Phone: 516-409-8495
  • Fax: 631-846-7925
Mailing address:
  • Phone: 516-383-1415
  • Fax: 631-846-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number010871
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: