Healthcare Provider Details

I. General information

NPI: 1790804565
Provider Name (Legal Business Name): VERNA MACCORNACK PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E 75TH ST
NEW YORK NY
10021-3240
US

IV. Provider business mailing address

239 CENTRAL PARK W
NEW YORK NY
10024-6038
US

V. Phone/Fax

Practice location:
  • Phone: 212-744-8778
  • Fax:
Mailing address:
  • Phone: 212-744-8778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6686
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6686
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6686
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number6686
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6686
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6686
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: