Provider Demographics
NPI:1366560203
Name:GREENWALD, DIANA LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:LEE
Last Name:GREENWALD
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 1:40 W 116TH ST
Mailing Address - Street 2:B403
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2864
Mailing Address - Country:US
Mailing Address - Phone:212-362-4856
Mailing Address - Fax:212-362-4856
Practice Address - Street 1:40 W 116TH ST
Practice Address - Street 2:B403
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2864
Practice Address - Country:US
Practice Address - Phone:212-362-4856
Practice Address - Fax:212-362-4856
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03184970Medicaid
NY03184970Medicaid