Healthcare Provider Details

I. General information

NPI: 1184903577
Provider Name (Legal Business Name): PARK EAST PSYCHOLOGICAL ASSOC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 EAST 68 ST.
NEW YORK NY
10065
US

IV. Provider business mailing address

3 EAST 68 ST.
NEW YORK NY
10065
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-9200
  • Fax: 212-472-7253
Mailing address:
  • Phone: 212-628-9200
  • Fax: 212-472-7253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number006485
License Number StateNY

VIII. Authorized Official

Name: JERRY ALAN LUBLIN
Title or Position: ASSISTANT DIRECTOR
Credential: PH.D.
Phone: 212-628-9200