Provider Demographics
NPI:1043823040
Name:TANENBAUM, LEA
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-4120
Mailing Address - Country:US
Mailing Address - Phone:914-217-3092
Mailing Address - Fax:
Practice Address - Street 1:230 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1328
Practice Address - Country:US
Practice Address - Phone:845-486-2703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY013621-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program