Provider Demographics
NPI:1649395286
Name:ROSENBAUM, MARION J (PHD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:J
Last Name:ROSENBAUM
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 1:45 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4010
Mailing Address - Country:US
Mailing Address - Phone:516-859-4878
Mailing Address - Fax:
Practice Address - Street 1:30 S BAYLES AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3754
Practice Address - Country:US
Practice Address - Phone:516-859-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014834103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist