Provider Demographics
NPI:1194505081
Name:PTAH, AMEN IMHOTEP
Entity type:Individual
Prefix:
First Name:AMEN
Middle Name:IMHOTEP
Last Name:PTAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HARPER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-3194
Mailing Address - Country:US
Mailing Address - Phone:585-284-0424
Mailing Address - Fax:
Practice Address - Street 1:480 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3634
Practice Address - Country:US
Practice Address - Phone:585-436-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist