Provider Demographics
NPI:1538296165
Name:ITSKOWITCH, MICHELE (LICENSED CLINICAL SO)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:ITSKOWITCH
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E 84 STREET
Mailing Address - Street 2:APT 15G
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10028
Mailing Address - Country:US
Mailing Address - Phone:212-734-5491
Mailing Address - Fax:212-987-8466
Practice Address - Street 1:1155 PARK AVENUE
Practice Address - Street 2:MEDICAL SUITE B
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10128
Practice Address - Country:US
Practice Address - Phone:212-734-5491
Practice Address - Fax:212-987-8466
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2540129OtherOXFORD INS
NYP2540129OtherOXFORD INS