Basic Information
Provider Information | |||||||||
NPI: | 1548258817 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIVIAN | ||||||||
FirstName: | DINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 696 | ||||||||
Address2: |   | ||||||||
City: | SAINT JAMES | ||||||||
State: | NY | ||||||||
PostalCode: | 117800696 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6315845261 | ||||||||
FaxNumber: | 6315845261 | ||||||||
Practice Location | |||||||||
Address1: | 1239 ROUTE 25A | ||||||||
Address2: | SUITE 6A | ||||||||
City: | STONY BROOK | ||||||||
State: | NY | ||||||||
PostalCode: | 117901934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316893483 | ||||||||
FaxNumber: | 6315845261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2005 | ||||||||
LastUpdateDate: | 11/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 009593 | NY | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TB0200X | 009593 | NY | N |   | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
ID | Type | State | Issuer | Description | P590784 | 01 | NY | OXFORD HEALTH INSURANCE | OTHER | 0038569 | 01 | NY | GHI | OTHER | 069201 | 01 | NM | VALUE OPTIONS | OTHER | 085652000 | 01 | NY | MAGELLAN BEHAVIORAL HEALT | OTHER |