Provider Demographics
NPI:1952040222
Name:LETANG, OLIVIER SERGE YVAN
Entity Type:Individual
Prefix:
First Name:OLIVIER
Middle Name:SERGE YVAN
Last Name:LETANG
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 1:620 WILSON AVE # 55
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2175
Mailing Address - Country:US
Mailing Address - Phone:718-717-2682
Mailing Address - Fax:
Practice Address - Street 1:40 W 13TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7940
Practice Address - Country:US
Practice Address - Phone:718-717-2682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1141102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst