Healthcare Provider Details

I. General information

NPI: 1407421712
Provider Name (Legal Business Name): HUMPHRIES THIRD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BEDFORD RD STE 340
MOUNT KISCO NY
10549-3444
US

IV. Provider business mailing address

100 S BEDFORD RD STE 340
MOUNT KISCO NY
10549-3444
US

V. Phone/Fax

Practice location:
  • Phone: 914-362-1083
  • Fax:
Mailing address:
  • Phone: 914-362-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHOSHANA D BERAN
Title or Position: OWNER
Credential: PSY.D.
Phone: 202-253-0408