Healthcare Provider Details

I. General information

NPI: 1952746166
Provider Name (Legal Business Name): JONATHAN KOGEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 BROADWAY
NEWBURGH NY
12550-5408
US

IV. Provider business mailing address

280 BROADWAY
NEWBURGH NY
12550-5408
US

V. Phone/Fax

Practice location:
  • Phone: 914-419-0088
  • Fax: 917-677-7131
Mailing address:
  • Phone: 914-419-0088
  • Fax: 917-677-7131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number003552
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: