Provider Demographics
NPI:1043827678
Name:LICHTENBERG, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LICHTENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 TOW PATH RD
Mailing Address - Street 2:
Mailing Address - City:ACCORD
Mailing Address - State:NY
Mailing Address - Zip Code:12404-5516
Mailing Address - Country:US
Mailing Address - Phone:718-813-0408
Mailing Address - Fax:
Practice Address - Street 1:236 TOW PATH RD
Practice Address - Street 2:
Practice Address - City:ACCORD
Practice Address - State:NY
Practice Address - Zip Code:12404-5516
Practice Address - Country:US
Practice Address - Phone:718-813-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NY013329103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent