Provider Demographics
NPI:1992891543
Name:REISINE, GEORGE M (PHD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:REISINE
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 1:299 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768
Mailing Address - Country:US
Mailing Address - Phone:631-757-6271
Mailing Address - Fax:
Practice Address - Street 1:299 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768
Practice Address - Country:US
Practice Address - Phone:631-757-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09954103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV6B201Medicare ID - Type Unspecified