Provider Demographics
NPI:1790958940
Name:JANOSON, MARC A (PHD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:JANOSON
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 1:75 PLANDOME RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2303
Mailing Address - Country:US
Mailing Address - Phone:516-304-5700
Mailing Address - Fax:516-304-5702
Practice Address - Street 1:75 PLANDOME RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-2303
Practice Address - Country:US
Practice Address - Phone:516-304-5700
Practice Address - Fax:516-304-5702
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006325103TC0700X, 103TA0700X, 103TF0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00432568Medicaid
NY006325OtherLICENSED PSYCHOLOGIST