Provider Demographics
NPI:1477187367
Name:AIVAZ, AMANDA (LP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AIVAZ
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MAYNARD ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-3436
Mailing Address - Country:US
Mailing Address - Phone:914-433-1414
Mailing Address - Fax:
Practice Address - Street 1:777 WESTCHESTER AVE STE 101
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-3520
Practice Address - Country:US
Practice Address - Phone:914-433-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001067102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst