Provider Demographics
NPI:1518346733
Name:PSYCHOTHERAPY PRIVATE PRACTICE
Entity Type:Organization
Organization Name:PSYCHOTHERAPY PRIVATE PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MIDORI
Authorized Official - Middle Name:PASION
Authorized Official - Last Name:REPP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:617-792-0264
Mailing Address - Street 1:166 ORCHARD ST
Mailing Address - Street 2:6D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-2282
Mailing Address - Country:US
Mailing Address - Phone:617-792-0264
Mailing Address - Fax:
Practice Address - Street 1:166 ORCHARD ST
Practice Address - Street 2:6D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2282
Practice Address - Country:US
Practice Address - Phone:617-792-0264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0793421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty