Provider Demographics
NPI:1063628279
Name:KURTZ, THEODORE STEPHEN
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:STEPHEN
Last Name:KURTZ
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:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-0529
Mailing Address - Country:US
Mailing Address - Phone:631-367-4440
Mailing Address - Fax:
Practice Address - Street 1:28 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-1413
Practice Address - Country:US
Practice Address - Phone:631-367-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000470102L00000X
NY000236106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist