Provider Demographics
NPI:1043661374
Name:WEINER, ELLIOT (PHD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:WEINER
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 1:4 W 101ST ST
Mailing Address - Street 2:APT 67
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4755
Mailing Address - Country:US
Mailing Address - Phone:718-514-0824
Mailing Address - Fax:
Practice Address - Street 1:14 E 4TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1155
Practice Address - Country:US
Practice Address - Phone:646-653-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020186-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical