| Doctor Name: | DR. MICHAEL LEONARD NISSENBAUM |
| NPI Number: | 1174546725 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | 010232 |
| Business Practice Address: | 2100 Middle Country Rd Suite 28w Centereach, NY - 117203577 |
| Business Phone Number: | 6317379500 |
| Business Fax Number: | 6317379512 |
| Mailing Address: | Po Box 625, CENTEREACH |
| State: | NY |
| Postal Code: | 117200625 |
| Phone Number: | 6317379500 |
| Fax Number: | 6317379512 |
| NPI Enumeration Date: | 07/25/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TB0200X |
| License Number: | 010232 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Cognitive & Behavioral |
| Taxonomy Definition: | |