Provider Demographics
NPI:1861917437
Name:SOSSIN, KENNETH MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:SOSSIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:K
Other - Middle Name:MARK
Other - Last Name:SOSSIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1893 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1623
Mailing Address - Country:US
Mailing Address - Phone:516-326-2401
Mailing Address - Fax:
Practice Address - Street 1:1893 STEWART AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1623
Practice Address - Country:US
Practice Address - Phone:516-326-2401
Practice Address - Fax:516-326-6973
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007858103TC0700X, 103T00000X
103TC2200X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007858OtherNYS LICENSED PSYCHOLOGIST