=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790298123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN KLEBANOFF PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2017
-----------------------------------------------------
Last Update Date | 11/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 UNIVERSITY PL FL 4
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-882-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 E 10TH ST APT 17H
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-5118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-882-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 009179
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------