=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114187390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEANNE DOMASH, PH.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 06/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 E 12TH ST #19D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-982-6672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 E 12TH ST #19D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-982-6672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEANNE DOMASH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-982-6672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | #4388
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------