Provider Demographics
NPI:1093108714
Name:ELEMBABY, MIKKI LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MIKKI
Middle Name:LEE
Last Name:ELEMBABY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2381 23RD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3407
Mailing Address - Country:US
Mailing Address - Phone:917-359-3986
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE RM 605
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4527
Practice Address - Country:US
Practice Address - Phone:917-359-3986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical