MEDICARE: MAYIMUNA Y PETTIFORD PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	019680	NY

General Provider Information

NPI Number	:	1902158538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYIMUNA Y PETTIFORD PH.D.

Provider Business Mailing Address
First Line	:	303 MERRICK RD
Second Line	:	SUITE 204
City	:	LYNBROOK
State	:	NY
Zip	:	11563-2501
Country	:	US
Telephone Number	:	800-725-6280
Fax Number	:	800-725-6380

Provider Business Practice Location Address
First Line	:	214 W HOUSTON ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10014-4846
Country	:	US
Telephone Number	:	212-337-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/05/2012

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