Provider Demographics
NPI:1639375819
Name:DR. CLIFFORD B. FISCH, PSYD PC
Entity Type:Organization
Organization Name:DR. CLIFFORD B. FISCH, PSYD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:B
Authorized Official - Last Name:FISCH
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:718-356-8629
Mailing Address - Street 1:702 BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1606
Mailing Address - Country:US
Mailing Address - Phone:718-356-8629
Mailing Address - Fax:718-761-3162
Practice Address - Street 1:702 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:718-356-8629
Practice Address - Fax:718-761-3162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02574874Medicaid
NY167144POtherHIP