Provider Demographics
NPI:1811507148
Name:MAGENHEIMER, MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MAGENHEIMER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 13TH PL NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2729
Mailing Address - Country:US
Mailing Address - Phone:516-857-1654
Mailing Address - Fax:
Practice Address - Street 1:4430 13TH PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2729
Practice Address - Country:US
Practice Address - Phone:516-857-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0810005605OtherPROFESSIONAL LICENSE NUMBER