Provider Demographics
NPI:1912026071
Name:TEITELBAUM, EZRA (DSW, LCSW)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:
Last Name:TEITELBAUM
Suffix:
Gender:M
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 W 96TH ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6522
Mailing Address - Country:US
Mailing Address - Phone:212-316-3358
Mailing Address - Fax:
Practice Address - Street 1:49 W 96TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6522
Practice Address - Country:US
Practice Address - Phone:212-316-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR 0107631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical