Basic Information
| Provider Information | |||||||||
| NPI: | 1932113198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENBERG | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 REMSEN ST | ||||||||
| Address2: | 5R | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6464254285 | ||||||||
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| 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: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 15300 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02587039 | 05 | NY | MEDICAID |