Provider Demographics
NPI:1487894077
Name:LICHT, CAROLYN ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ANN
Last Name:LICHT
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 1:590 W END AVE
Mailing Address - Street 2:APT. 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1722
Mailing Address - Country:US
Mailing Address - Phone:646-660-0884
Mailing Address - Fax:646-304-6804
Practice Address - Street 1:7 W 86TH ST
Practice Address - Street 2:SUITE 1AA
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3603
Practice Address - Country:US
Practice Address - Phone:646-660-0884
Practice Address - Fax:646-304-6804
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017934103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26-4132188OtherEMPLOYER IDENTIFICATION NUMBER