=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952464059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL HEALTH CARE OF NY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 05/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2797 OCEAN PKWY
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-7861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-743-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 ORIENTAL BLVD APT 12C
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-332-6025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL E KISSIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 718-332-6025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 009369
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------