Provider Demographics
NPI:1720268451
Name:LITTLE PENGUIN
Entity Type:Organization
Organization Name:LITTLE PENGUIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIROCHNIK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-967-1585
Mailing Address - Street 1:48 BLUEBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:STATE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:718-967-1585
Mailing Address - Fax:718-967-1585
Practice Address - Street 1:48 BLUEBERRY LANE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312
Practice Address - Country:US
Practice Address - Phone:718-967-1585
Practice Address - Fax:718-967-1585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR065562103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN3W281Medicare UPIN