Provider Demographics
NPI:1164445771
Name:KLEINMAN, MARK JACOB (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JACOB
Last Name:KLEINMAN
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 1:144 NEHRING AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6120
Mailing Address - Country:US
Mailing Address - Phone:917-595-7520
Mailing Address - Fax:
Practice Address - Street 1:3915 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3425
Practice Address - Country:US
Practice Address - Phone:718-948-7800
Practice Address - Fax:718-948-1733
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010039103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02400397Medicaid