Healthcare Provider Details

I. General information

NPI: 1174556443
Provider Name (Legal Business Name): MICHELLE MANUALA LE BOW PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W 72ND ST SUITE 1103
NEW YORK NY
10023-4100
US

IV. Provider business mailing address

40 W 77TH ST APT #7F
NEW YORK NY
10024-5128
US

V. Phone/Fax

Practice location:
  • Phone: 212-724-8767
  • Fax:
Mailing address:
  • Phone: 212-724-8767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number000534-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: