Provider Demographics
NPI:1336490382
Name:THEISE, RACHELLE SILVER
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:SILVER
Last Name:THEISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:THEISE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5802
Mailing Address - Country:US
Mailing Address - Phone:646-754-4978
Mailing Address - Fax:
Practice Address - Street 1:1 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5802
Practice Address - Country:US
Practice Address - Phone:646-754-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-29
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019812-1103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral