Provider Demographics
NPI:1205009511
Name:MICHAEL L NISSNBAUM, PH.D., PSYCHOLOGIST, P.C.
Entity Type:Organization
Organization Name:MICHAEL L NISSNBAUM, PH.D., PSYCHOLOGIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:NISSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-737-9500
Mailing Address - Street 1:4 COED LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2704
Mailing Address - Country:US
Mailing Address - Phone:631-737-9500
Mailing Address - Fax:631-737-9512
Practice Address - Street 1:4 COED LN
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2704
Practice Address - Country:US
Practice Address - Phone:631-737-9500
Practice Address - Fax:631-737-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010232103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR53044Medicare UPIN
NYWCK191Medicare PIN