Provider Demographics
NPI:1760822340
Name:BURNBAUM, JEAN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:BURNBAUM
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 1:75 PROSPECT ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3382
Mailing Address - Country:US
Mailing Address - Phone:631-219-5670
Mailing Address - Fax:
Practice Address - Street 1:75 PROSPECT ST
Practice Address - Street 2:SUITE 116
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3382
Practice Address - Country:US
Practice Address - Phone:631-219-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0200082-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical