Provider Demographics
NPI:1316136617
Name:LEISEROWITZ, SMADAR (PSYD)
Entity type:Individual
Prefix:
First Name:SMADAR
Middle Name:
Last Name:LEISEROWITZ
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 1:204 HUNTINGTON ST
Mailing Address - Street 2:#1D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3970
Mailing Address - Country:US
Mailing Address - Phone:646-596-2866
Mailing Address - Fax:
Practice Address - Street 1:910 W END AVE
Practice Address - Street 2:1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3533
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-932-0964
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02935793Medicaid