Healthcare Provider Details

I. General information

NPI: 1134312572
Provider Name (Legal Business Name): SHIBANI RAY MAZUMDER PH.D, SC.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 09/08/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E 30TH ST APT 9A
NEW YORK NY
10016-8298
US

IV. Provider business mailing address

466 W 153RD ST
NEW YORK NY
10031-1101
US

V. Phone/Fax

Practice location:
  • Phone: 631-786-9312
  • Fax: 212-263-8995
Mailing address:
  • Phone: 631-786-9312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number020691
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: