Provider Demographics
NPI:1629506456
Name:MERBAUM, AMY ALTHOFF (LP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ALTHOFF
Last Name:MERBAUM
Suffix:
Gender:F
Credentials:LP
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:ALTHOFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LP
Mailing Address - Street 1:6820 BURNS ST APT D4
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 W 10TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8707
Practice Address - Country:US
Practice Address - Phone:917-747-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPO5952102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH82-1155629OtherIRS