Provider Demographics
NPI:1225233851
Name:JELLINEKMANSSON, ROBERTA (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:JELLINEKMANSSON
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 1:595 W END AVE
Mailing Address - Street 2:7B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1727
Mailing Address - Country:US
Mailing Address - Phone:212-799-9787
Mailing Address - Fax:212-799-9787
Practice Address - Street 1:595 W END AVE
Practice Address - Street 2:7B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1727
Practice Address - Country:US
Practice Address - Phone:212-799-9787
Practice Address - Fax:212-799-9787
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002850-1101YM0800X
NY000744-1102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst