Provider Demographics
NPI:1245220169
Name:JOHN, MIRIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:
Last Name:JOHN
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 1:2 WASHINGTON SQ APT 6A
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-2019
Mailing Address - Country:US
Mailing Address - Phone:914-833-1125
Mailing Address - Fax:914-833-7873
Practice Address - Street 1:2 WASHINGTON SQ APT 6A
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-2019
Practice Address - Country:US
Practice Address - Phone:914-833-1125
Practice Address - Fax:914-833-7873
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-22
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4441103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV40951Medicare ID - Type Unspecified
NYV40951Medicare UPIN