=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679792444
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH WEISSBLUM PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 5TH AVE SUITE 1004, RM #6
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-8018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-579-1943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 E 71ST ST APT 5H
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-5277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-579-1943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number | 000031
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------