Basic Information
Provider Information | |||||||||
NPI: | 1316136617 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEISEROWITZ | ||||||||
FirstName: | SMADAR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 HUNTINGTON ST | ||||||||
Address2: | #1D | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112313970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6465962866 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 910 W END AVE | ||||||||
Address2: | 1C | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100253533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2128518100 | ||||||||
FaxNumber: | 2129320964 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2007 | ||||||||
LastUpdateDate: | 03/31/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 17367 | NY | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 02935793 | 05 | NY |   | MEDICAID |