Healthcare Provider Details

I. General information

NPI: 1548258817
Provider Name (Legal Business Name): DINA VIVIAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 ROUTE 25A SUITE 6A
STONY BROOK NY
11790-1934
US

IV. Provider business mailing address

PO BOX 696
SAINT JAMES NY
11780-0696
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-3483
  • Fax: 631-584-5261
Mailing address:
  • Phone: 631-584-5261
  • Fax: 631-584-5261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number009593
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number009593
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: