Provider Demographics
NPI:1720814015
Name:REIFEN, CHANAN
Entity type:Individual
Prefix:
First Name:CHANAN
Middle Name:
Last Name:REIFEN
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 1:80 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-3919
Mailing Address - Country:US
Mailing Address - Phone:401-473-1111
Mailing Address - Fax:
Practice Address - Street 1:160 W 86TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4018
Practice Address - Country:US
Practice Address - Phone:212-875-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6722100A103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244335Medicaid