Healthcare Provider Details

I. General information

NPI: 1669455416
Provider Name (Legal Business Name): ELIZABETH HEGEMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 W END AVE SUITE LE
NEW YORK NY
10024-4329
US

IV. Provider business mailing address

100 RIVERSIDE DR 10C
NEW YORK NY
10024-4822
US

V. Phone/Fax

Practice location:
  • Phone: 212-877-3007
  • Fax:
Mailing address:
  • Phone: 212-874-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number004431
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: