Provider Demographics
NPI:1013414705
Name:NEW YORK STATE NEUROPSYCHOLOGICAL STATE OF MIND PC
Entity Type:Organization
Organization Name:NEW YORK STATE NEUROPSYCHOLOGICAL STATE OF MIND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSY.D
Authorized Official - Prefix:
Authorized Official - First Name:SANAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFEEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-441-0166
Mailing Address - Street 1:8460 123RD ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3305
Mailing Address - Country:US
Mailing Address - Phone:718-441-0166
Mailing Address - Fax:718-805-2054
Practice Address - Street 1:8460 123RD ST
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3305
Practice Address - Country:US
Practice Address - Phone:718-441-0166
Practice Address - Fax:718-805-2054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016117103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02936607Medicaid