Provider Demographics
NPI:1336261775
Name:KISSEN, MORTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:MORTON
Middle Name:
Last Name:KISSEN
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 1:27 OLD HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2526
Mailing Address - Country:US
Mailing Address - Phone:631-423-5302
Mailing Address - Fax:631-421-4174
Practice Address - Street 1:27 OLD HICKORY LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2526
Practice Address - Country:US
Practice Address - Phone:631-423-5302
Practice Address - Fax:631-421-4174
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3551103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV55812Medicare ID - Type UnspecifiedMEDICARE PROVIDER #