Provider Demographics
NPI:1447726419
Name:KAMINETZKY, ELLIOT (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:
Last Name:KAMINETZKY
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 1:90 BROAD ST STE 323
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2205
Mailing Address - Country:US
Mailing Address - Phone:646-580-4572
Mailing Address - Fax:
Practice Address - Street 1:90 BROAD ST STE 323
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2205
Practice Address - Country:US
Practice Address - Phone:646-580-4572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022872103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY83-2032785OtherIRS