Provider Demographics
NPI:1427106020
Name:LIN, PETER (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4238 204TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2627
Mailing Address - Country:US
Mailing Address - Phone:347-512-0311
Mailing Address - Fax:
Practice Address - Street 1:177 PRINCE ST
Practice Address - Street 2:SUITE 407
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2946
Practice Address - Country:US
Practice Address - Phone:347-512-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2009-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016334-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02840779Medicaid
NYVN3841Medicare PIN