Provider Demographics
NPI:1568860013
Name:TANENBAUM, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CONASHAUGH TRL
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-3905
Mailing Address - Country:US
Mailing Address - Phone:845-467-1207
Mailing Address - Fax:
Practice Address - Street 1:356 MEADOW AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3038
Practice Address - Country:US
Practice Address - Phone:845-564-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18005613101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03448515Medicaid