Provider Demographics
NPI:1265592893
Name:LITKE, DAVID ROY (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROY
Last Name:LITKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2345
Mailing Address - Country:US
Mailing Address - Phone:973-440-9917
Mailing Address - Fax:
Practice Address - Street 1:600 3RD AVE FL 2
Practice Address - Street 2:NYPHD LLC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1919
Practice Address - Country:US
Practice Address - Phone:646-739-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02209492Medicaid
NJ20-2451471OtherEIN
NY02209492Medicaid