Provider Demographics
NPI:1679792444
Name:WEISSBLUM, KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:WEISSBLUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E 71ST ST APT 5H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5277
Mailing Address - Country:US
Mailing Address - Phone:917-579-1943
Mailing Address - Fax:
Practice Address - Street 1:80 5TH AVE SUITE 1004, RM #6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8018
Practice Address - Country:US
Practice Address - Phone:917-579-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000031102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst