Provider Demographics
NPI:1629079785
Name:PELTZ, LINDA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:G
Last Name:PELTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 N BROADWAY
Mailing Address - Street 2:SUITE 404
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2025
Mailing Address - Country:US
Mailing Address - Phone:516-935-1610
Mailing Address - Fax:
Practice Address - Street 1:366 N BROADWAY
Practice Address - Street 2:SUITE 404
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2025
Practice Address - Country:US
Practice Address - Phone:516-935-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005728103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY550893652OtherFEDERAL EIN
NY550893652OtherFEDERAL EIN