=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497148373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELE D KOFMAN PSYCHOLOGIST PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2015
-----------------------------------------------------
Last Update Date | 03/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 W 70TH ST SUITE 01
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-405-3991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 W 70TH ST SUITE 01
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHELE KOFMAN
-----------------------------------------------------
Credential | PHD MPH
-----------------------------------------------------
Telephone | 917-405-3991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 0178791
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------