Provider Demographics
NPI:1114053865
Name:LAVI, BRENDA H (PHD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:H
Last Name:LAVI
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 1:31 MERRICK AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566
Mailing Address - Country:US
Mailing Address - Phone:516-379-7100
Mailing Address - Fax:
Practice Address - Street 1:1155 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128
Practice Address - Country:US
Practice Address - Phone:917-239-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0102121103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP83405683OtherMULTIPLAN
NY068423OtherVALUE OPTIONS
NY6800205OtherGHI
NYAB00778OtherMDNY
NYP441747OtherOXFORD
NYV67251Medicare ID - Type Unspecified