Provider Demographics
NPI:1972675114
Name:ITZKOWITZ, PHYLLIS (DSW)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:ITZKOWITZ
Suffix:
Gender:F
Credentials:DSW
Other - Prefix:DR
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:MERVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DSW
Mailing Address - Street 1:125 E 87TH ST
Mailing Address - Street 2:17C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1124
Mailing Address - Country:US
Mailing Address - Phone:212-369-8879
Mailing Address - Fax:212-534-6774
Practice Address - Street 1:125 E 87TH ST
Practice Address - Street 2:SUITE 17C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1124
Practice Address - Country:US
Practice Address - Phone:212-369-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR12875101YM0800X
NYPR127851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPR12875 LCSWOtherSTATE LICENSE #
NYN21471Medicare ID - Type Unspecified