Provider Demographics
NPI:1265655419
Name:CIVIN, MICHAEL A I (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:CIVIN
Suffix:I
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 1:696 E 187TH ST
Mailing Address - Street 2:205-208
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-6800
Mailing Address - Country:US
Mailing Address - Phone:516-641-6358
Mailing Address - Fax:
Practice Address - Street 1:696 E 187TH ST
Practice Address - Street 2:205-208
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6800
Practice Address - Country:US
Practice Address - Phone:516-641-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
NY010129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01174941Medicaid
NYVN4212Medicare PIN