1376891291 NPI number — PARK AVE. PSYCHOTHERAPY GROUP

Table of content: (NPI 1376891291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376891291 NPI number — PARK AVE. PSYCHOTHERAPY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK AVE. PSYCHOTHERAPY GROUP
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:
NY GROUP FOR PSYCHOTHERAPIES
Provider Other Organization Name Type Code:
4
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:
1376891291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
167 BEACH 135
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKAWAY PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11694-1303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-634-0253
Provider Business Mailing Address Fax Number:
718-634-1056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 BEACH 135
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKAWAY PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11694-1303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-634-0253
Provider Business Practice Location Address Fax Number:
718-634-1056
Provider Enumeration Date:
08/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GITTER
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
RHONDA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
718-634-0253

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R027402 , 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: R027402 . This is a "NYS LIC." identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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