Provider Demographics
NPI:1083199616
Name:SONG, VIVIAN (PHD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:SONG
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 1:142 JORALEMON ST STE 3E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4709
Mailing Address - Country:US
Mailing Address - Phone:718-935-0400
Mailing Address - Fax:
Practice Address - Street 1:142 JORALEMON ST STE 3E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4709
Practice Address - Country:US
Practice Address - Phone:718-935-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent