Provider Demographics
NPI:1407870348
Name:CHAN, TINA (PHD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CHAN
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 1:63 OLD STONE HILL RD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-1518
Mailing Address - Country:US
Mailing Address - Phone:860-748-8709
Mailing Address - Fax:
Practice Address - Street 1:156 W 56TH ST STE 1804
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3878
Practice Address - Country:US
Practice Address - Phone:212-851-8102
Practice Address - Fax:888-977-2547
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16515103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708661Medicaid
NY02708661Medicaid