Healthcare Provider Details

I. General information

NPI: 1891130167
Provider Name (Legal Business Name): MARK BUENZLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 W 10TH ST CENTER FOR MODERN PSYCHOANALYTIC STUDIES
NEW YORK NY
10011-8707
US

IV. Provider business mailing address

294 BRONXVILLE RD 5G
BRONXVILLE NY
10708-2850
US

V. Phone/Fax

Practice location:
  • Phone: 917-478-0677
  • Fax:
Mailing address:
  • Phone: 917-478-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000894-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: