Provider Demographics
NPI:1699001248
Name:EDISON, MARK R (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:EDISON
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 1:1165 PARK AVE
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1210
Mailing Address - Country:US
Mailing Address - Phone:917-399-5594
Mailing Address - Fax:
Practice Address - Street 1:1165 PARK AVE
Practice Address - Street 2:SUITE 1-B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1210
Practice Address - Country:US
Practice Address - Phone:917-399-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016913-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical