Provider Demographics
NPI:1104848084
Name:ELITZUR, BARUCH (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARUCH
Middle Name:
Last Name:ELITZUR
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 1:32 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1131
Mailing Address - Country:US
Mailing Address - Phone:631-547-9191
Mailing Address - Fax:
Practice Address - Street 1:32 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1131
Practice Address - Country:US
Practice Address - Phone:631-547-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004676-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY468882OtherVALUE OPTIONS
NYEB865200OtherGHI
NYEB865200OtherGHI