Provider Demographics
NPI:1295733699
Name:KRIVOSHEY, MATTHEW ALAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALAN
Last Name:KRIVOSHEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ASHFORD LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4874
Mailing Address - Country:US
Mailing Address - Phone:631-630-4620
Mailing Address - Fax:631-754-3654
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 110#9
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-630-4620
Practice Address - Fax:631-754-3654
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014389103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVS1211Medicare PIN