Basic Information
| Provider Information | |||||||||
| NPI: | 1659395929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25-114 BARKER ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105491648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144202395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 156 W 56TH ST STE 1804 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100193878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518100 | ||||||||
| FaxNumber: | 8889772547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 13007 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01791877 | 05 | NY | MEDICAID | 680009410 | 01 | NY | RAILROAD MEDICARE | OTHER |