Provider Demographics
NPI:1427100791
Name:GOLOMB, ELAN PHOEBE
Entity type:Individual
Prefix:
First Name:ELAN
Middle Name:PHOEBE
Last Name:GOLOMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLARK ST
Mailing Address - Street 2:10E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2743
Mailing Address - Country:US
Mailing Address - Phone:718-923-0408
Mailing Address - Fax:212-496-4175
Practice Address - Street 1:412 6TH AVE
Practice Address - Street 2:710
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8409
Practice Address - Country:US
Practice Address - Phone:212-496-6003
Practice Address - Fax:212-496-4175
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV27541OtherMEDICARE PTAN