Provider Demographics
NPI:1962572362
Name:PINE BUSH MENTAL HEALTH, LLP
Entity type:Organization
Organization Name:PINE BUSH MENTAL HEALTH, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:POLANIK
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-862-1665
Mailing Address - Street 1:1A PINE WEST PLZ
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5556
Mailing Address - Country:US
Mailing Address - Phone:518-862-1665
Mailing Address - Fax:518-862-1668
Practice Address - Street 1:1A PINE WEST PLZ
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5556
Practice Address - Country:US
Practice Address - Phone:518-862-1665
Practice Address - Fax:518-862-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty