Provider Demographics
NPI:1548258817
Name:VIVIAN, DINA (PHD)
Entity type:Individual
Prefix:DR
First Name:DINA
Middle Name:
Last Name:VIVIAN
Suffix:
Gender:F
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:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-0696
Mailing Address - Country:US
Mailing Address - Phone:631-584-5261
Mailing Address - Fax:631-584-5261
Practice Address - Street 1:1239 ROUTE 25A
Practice Address - Street 2:SUITE 6A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1934
Practice Address - Country:US
Practice Address - Phone:631-689-3483
Practice Address - Fax:631-584-5261
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009593103TC0700X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP590784OtherOXFORD HEALTH INSURANCE
NY0038569OtherGHI
NM069201OtherVALUE OPTIONS
NY085652000OtherMAGELLAN BEHAVIORAL HEALT
NYP590784OtherOXFORD HEALTH INSURANCE