Healthcare Provider Details

I. General information

NPI: 1871145417
Provider Name (Legal Business Name): MADHUVANTHI SURESH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

700 HICKSVILLE RD STE 205
BETHPAGE NY
11714-3472
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-6159
  • Fax: 646-501-9872
Mailing address:
  • Phone: 646-501-3229
  • Fax: 212-263-4539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number025745-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: