Provider Demographics
NPI:1710079751
Name:BENZAQUEN PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:BENZAQUEN PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:BENZAQUEN PSYCHOLOGICAL SERVICES, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:BENZAQUEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:516-295-4104
Mailing Address - Street 1:3229 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4233
Mailing Address - Country:US
Mailing Address - Phone:516-295-4104
Mailing Address - Fax:516-764-7833
Practice Address - Street 1:143 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2225
Practice Address - Country:US
Practice Address - Phone:516-295-4104
Practice Address - Fax:516-764-7833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9097-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02870166Medicaid
NY02870166Medicaid
NY07968Medicare PIN