Healthcare Provider Details

I. General information

NPI: 1003241225
Provider Name (Legal Business Name): MAXINE L. GANN PSYCHOLOGIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PARK AVE SUITE 1K
NEW YORK NY
10128-1711
US

IV. Provider business mailing address

8 E 96TH ST SUITE 5A
NEW YORK NY
10128-0706
US

V. Phone/Fax

Practice location:
  • Phone: 212-860-3368
  • Fax: 212-202-3890
Mailing address:
  • Phone: 212-860-3368
  • Fax: 212-202-3890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7966
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7966
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number7966
License Number StateNY

VIII. Authorized Official

Name: DR. MAXINE L. GANN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 212-860-3368