Provider Demographics
NPI:1023026754
Name:BANILIVY, MANSOUR (MAX) (PHD)
Entity Type:Individual
Prefix:DR
First Name:MANSOUR (MAX)
Middle Name:
Last Name:BANILIVY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 MERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4622
Mailing Address - Country:US
Mailing Address - Phone:516-627-9432
Mailing Address - Fax:516-867-0013
Practice Address - Street 1:2615 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4622
Practice Address - Country:US
Practice Address - Phone:516-627-9432
Practice Address - Fax:516-867-0013
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00795840Medicaid
NY00795840Medicaid