Provider Demographics
NPI:1497392153
Name:MEDARD, HANZ PHILLIPE
Entity Type:Individual
Prefix:
First Name:HANZ
Middle Name:PHILLIPE
Last Name:MEDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 WINDING ROAD FARM E
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502-2711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 WINDING ROAD FARM E
Practice Address - Street 2:
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-2711
Practice Address - Country:US
Practice Address - Phone:914-400-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001856103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst