Provider Demographics
NPI:1982820403
Name:EDELSTEIN, RIVCKA (PHD)
Entity Type:Individual
Prefix:DR
First Name:RIVCKA
Middle Name:
Last Name:EDELSTEIN
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 1:125 PLEASANT ST APT 609
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-7183
Mailing Address - Country:US
Mailing Address - Phone:617-277-1961
Mailing Address - Fax:
Practice Address - Street 1:1394 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2205
Practice Address - Country:US
Practice Address - Phone:617-429-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8090-1103T00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY058472OtherVALUE OPTIONS
NY81182000OtherMAGELLAN BEHAVIORAL HEALT
NYV5332OtherEMPIRE BLUE CROSS
NY81182000OtherMAGELLAN BEHAVIORAL HEALT