=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013135607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE SPIVAK PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2007
-----------------------------------------------------
Last Update Date | 12/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 FIRE ISLAND AVE. STE. 103
-----------------------------------------------------
City | BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-661-1922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 FIRE ISLAND AVE STE. 103
-----------------------------------------------------
City | BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11702-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-661-1922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R037378-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------