Provider Demographics
NPI:1073636627
Name:SACKS, MICHELE CARYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:CARYN
Last Name:SACKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-1439
Mailing Address - Country:US
Mailing Address - Phone:914-834-2652
Mailing Address - Fax:
Practice Address - Street 1:48 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-1439
Practice Address - Country:US
Practice Address - Phone:914-834-2652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10080103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV60821Medicare ID - Type Unspecified