Provider Demographics
NPI:1790843654
Name:BLAU, ALAN
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:BLAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2519
Mailing Address - Country:US
Mailing Address - Phone:718-434-4600
Mailing Address - Fax:718-434-6261
Practice Address - Street 1:1221 EAST 17 STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-434-4600
Practice Address - Fax:718-434-6261
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010451-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010451Medicaid
NY010451Medicaid