1245574201 NPI number — DR. RUBY YEDLOUTSCHNIG PSYD

Table of content: DR. RUBY YEDLOUTSCHNIG PSYD (NPI 1245574201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245574201 NPI number — DR. RUBY YEDLOUTSCHNIG PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YEDLOUTSCHNIG
Provider First Name:
RUBY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245574201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 W BRADFORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR GROVE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07009-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-830-1057
Provider Business Mailing Address Fax Number:
973-604-4259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 W BRADFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR GROVE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07009-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-830-1057
Provider Business Practice Location Address Fax Number:
973-604-4259
Provider Enumeration Date:
11/15/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  35SI00567000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 022127-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)