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General NPI Number Information
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NPI Number | 1205009511
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Entity Type | Organization
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Legal Business Name | MICHAEL L NISSNBAUM, PH.D., PSYCHOLOGIST, P.C.
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Dates
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Enumeration Date | 04/08/2008
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Last Update Date | 07/01/2008
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Provider Practice Location Address
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Address Line | 4 COED LN
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City | STONY BROOK
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State | NY
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Zip | 11790-2704
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Country | US
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Telephone | 631-737-9500
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Fax | 631-737-9512
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Provider Business Mailing Address
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Address Line | 4 COED LN
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City | STONY BROOK
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State | NY
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Zip | 11790-2704
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Country | US
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Telephone | 631-737-9500
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Fax | 631-737-9512
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MICHAEL LEONARD NISSENBAUM
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Credential | PH.D.
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Telephone | 631-737-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 010232
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License Number State | NY
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