Provider Demographics
NPI:1568525996
Name:MICHAELIS, BENJAMIN HOWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HOWARD
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CABRINI BLVD
Mailing Address - Street 2:APARTMENT 8K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3635
Mailing Address - Country:US
Mailing Address - Phone:917-992-0120
Mailing Address - Fax:
Practice Address - Street 1:590 W END AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1722
Practice Address - Country:US
Practice Address - Phone:917-992-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016348103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02689370Medicaid
NYVM8781Medicare ID - Type Unspecified
NY02689370Medicaid