1811165848 NPI number — OPTIMUM PSYCHOLOGICAL SERVICES PLLC

Table of content: (NPI 1811165848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811165848 NPI number — OPTIMUM PSYCHOLOGICAL SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMUM PSYCHOLOGICAL SERVICES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1811165848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 58TH ST STE 3R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11220-3609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-437-3558
Provider Business Mailing Address Fax Number:
718-437-6368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 58TH ST STE 3R
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11220-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-437-3558
Provider Business Practice Location Address Fax Number:
718-437-6368
Provider Enumeration Date:
02/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NG
Authorized Official First Name:
EVA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PSYCHOLOGIST
Authorized Official Telephone Number:
718-437-3558

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  014422 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02145646 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1057050 . This is a "BEACON" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1096512 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 494112 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 112590201 . This is a "HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 060014422NY01 . This is a "ANTHEM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 228709P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 486556000 . This is a "MAGELLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7563424 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 073609645 . This is a "1199" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 251261 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 108388348 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 251261 . This is a "MHN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 286951 . This is a "WELL CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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