Provider Demographics
NPI:1629125455
Name:NATHAN, MYRA MALMED (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:MALMED
Last Name:NATHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 NEW LOUDON RD
Mailing Address - Street 2:SUITE 245
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2100
Mailing Address - Country:US
Mailing Address - Phone:518-785-7360
Mailing Address - Fax:518-785-7360
Practice Address - Street 1:950 NEW LOUDON RD
Practice Address - Street 2:SUITE 245
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2100
Practice Address - Country:US
Practice Address - Phone:518-785-7360
Practice Address - Fax:518-785-7360
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10227-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01667803Medicaid
NY137498OtherVALUE OPTIONS
NY137498OtherVALUE OPTIONS
NY01667803Medicaid