Provider Demographics
NPI:1912008160
Name:NOMBERG, MADELINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:
Last Name:NOMBERG
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 1:103 E 86TH ST
Mailing Address - Street 2:2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-1058
Mailing Address - Country:US
Mailing Address - Phone:212-410-6991
Mailing Address - Fax:212-831-0660
Practice Address - Street 1:103 E 86TH ST
Practice Address - Street 2:2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1058
Practice Address - Country:US
Practice Address - Phone:212-410-6991
Practice Address - Fax:212-831-0660
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016336103T00000X
NY103TC0700X103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7350619OtherGHI
NYVM9521Medicare PIN
NYQ55792Medicare UPIN