Provider Demographics
NPI:1184225849
Name:STREET, LINDA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:L
Last Name:STREET
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 1:165 SAINT REGIS DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-3454
Mailing Address - Country:US
Mailing Address - Phone:516-672-6746
Mailing Address - Fax:
Practice Address - Street 1:165 SAINT REGIS DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-3454
Practice Address - Country:US
Practice Address - Phone:516-672-6746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty