Provider Demographics
NPI:1053488361
Name:KISSIN, MICHAEL E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:KISSIN
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 1:65 ORIENTAL BLVD
Mailing Address - Street 2:SUITE 12C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4945
Mailing Address - Country:US
Mailing Address - Phone:718-332-6025
Mailing Address - Fax:
Practice Address - Street 1:2797 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7861
Practice Address - Country:US
Practice Address - Phone:718-332-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009369103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY654049OtherUHC
NYV41631OtherBLUE CROSS BLUE SHEILD ID
NY01499105Medicaid
NY7348273OtherGHI PROV #
NY009369OtherLICENCE #
NY009369OtherHIP PROV.#
NY4571094OtherAETNA PROV. #
NY000207890201OtherHEALTH PLUS PROV.#
NYV41631Medicare PIN