Provider Demographics
NPI:1811068943
Name:WEISER, LYLE MITCHELL (PHD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:MITCHELL
Last Name:WEISER
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 1:7 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2623
Mailing Address - Country:US
Mailing Address - Phone:631-325-2113
Mailing Address - Fax:631-610-8954
Practice Address - Street 1:7 SCOTT LN
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2623
Practice Address - Country:US
Practice Address - Phone:631-325-2113
Practice Address - Fax:631-610-8954
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV3C371Medicare ID - Type UnspecifiedPSYCHOLOGIST