Provider Demographics
NPI:1124071485
Name:WEISMAN, MAXINE (PSYD)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:WEISMAN
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 1:315 METCALF ST
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5687
Mailing Address - Country:US
Mailing Address - Phone:914-772-3230
Mailing Address - Fax:
Practice Address - Street 1:315 METCALF ST
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5687
Practice Address - Country:US
Practice Address - Phone:914-772-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008818103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940Medicaid
NY008818OtherNYS LICENSE #
NY1285628552OtherJDAM NPI #
NY02948598Medicaid
NYWVE061Medicare PIN
NYVB942Medicare PIN