Provider Demographics
NPI:1417006982
Name:FELIXBROD, JEFFREY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:FELIXBROD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:J
Other - Last Name:FELIXBROD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:228 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2322
Mailing Address - Country:US
Mailing Address - Phone:516-294-5000
Mailing Address - Fax:516-294-5454
Practice Address - Street 1:228 BIRCH DR
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2322
Practice Address - Country:US
Practice Address - Phone:516-294-5000
Practice Address - Fax:516-294-5454
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004682103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV22351Medicare ID - Type Unspecified