Provider Demographics
NPI:1255536801
Name:GREENBLATT, RENA MATISON (PHD)
Entity type:Individual
Prefix:DR
First Name:RENA
Middle Name:MATISON
Last Name:GREENBLATT
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 1:1160 FIFTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 FIFTH AVENUE
Practice Address - Street 2:STE 112
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-828-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0091801103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005235199OtherGHI
NYV823T1Medicare ID - Type Unspecified