Provider Demographics
NPI:1821149394
Name:WORMHOUDT, JONATHAN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:WORMHOUDT
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 1:70 E 10TH ST
Mailing Address - Street 2:APATMENT 18D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-5102
Mailing Address - Country:US
Mailing Address - Phone:212-242-9494
Mailing Address - Fax:212-242-9494
Practice Address - Street 1:460 W 24TH ST APT 1F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1366
Practice Address - Country:US
Practice Address - Phone:212-242-9494
Practice Address - Fax:212-242-9494
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015443103T00000X
CAPSY11307103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist