Provider Demographics
NPI:1629113964
Name:THEG, B. ELLEN (LIC PSYCHOANALYST)
Entity Type:Individual
Prefix:MS
First Name:B.
Middle Name:ELLEN
Last Name:THEG
Suffix:
Gender:F
Credentials:LIC PSYCHOANALYST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 N BROADWAY
Mailing Address - Street 2:#30
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-1064
Mailing Address - Country:US
Mailing Address - Phone:914-478-4714
Mailing Address - Fax:
Practice Address - Street 1:645 N BROADWAY
Practice Address - Street 2:#30
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706-1064
Practice Address - Country:US
Practice Address - Phone:914-478-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000619-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000619-1OtherLICENSED PSYCHOANALYST