Healthcare Provider Details

I. General information

NPI: 1720268451
Provider Name (Legal Business Name): LITTLE PENGUIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 BLUEBERRY LANE
STATEN ISLAND NY
10312
US

IV. Provider business mailing address

48 BLUEBERRY LANE
STATE ISLAND NY
10312
US

V. Phone/Fax

Practice location:
  • Phone: 718-967-1585
  • Fax: 718-967-1585
Mailing address:
  • Phone: 718-967-1585
  • Fax: 718-967-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberR065562
License Number StateNY

VIII. Authorized Official

Name: MR. BORIS MIROCHNIK
Title or Position: DIRECTOR PSYCHOLOGIST
Credential: LCSW
Phone: 718-967-1585