Provider Demographics
NPI:1013049279
Name:ACADEMIC HEALTH PSYCHOLOGY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ACADEMIC HEALTH PSYCHOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LACKNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:716-898-5671
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-0093
Mailing Address - Country:US
Mailing Address - Phone:716-898-5671
Mailing Address - Fax:716-898-3040
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:ROOM G208
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-5671
Practice Address - Fax:716-898-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012051-1103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000523299002OtherBLUE CROSS ID NUMBER
NYDF1724OtherRR MEDICARE
NY00025302101OtherUNIVERA ID NUMBER
NY6108856OtherIHA ID NUMBER
NY6108856OtherIHA ID NUMBER