Provider Demographics
NPI:1033161104
Name:FOREBRAIN PLLC
Entity Type:Organization
Organization Name:FOREBRAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIED
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:917-922-1751
Mailing Address - Street 1:58 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2750
Mailing Address - Country:US
Mailing Address - Phone:212-620-0488
Mailing Address - Fax:
Practice Address - Street 1:7917 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1703
Practice Address - Country:US
Practice Address - Phone:917-922-1751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011416103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02742978Medicaid