Provider Demographics
NPI:1588757975
Name:WEBER, MIRIAM T (PHD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:T
Last Name:WEBER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1351 MOUNT HOPE AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3917
Mailing Address - Country:US
Mailing Address - Phone:585-273-3507
Mailing Address - Fax:585-242-9164
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 278984
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-273-3507
Practice Address - Fax:585-242-9164
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY16859103G00000X
NY016859103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02818413Medicaid
NYJ400021549Medicare PIN