Provider First Line Business Practice Location Address: 
10470 QUEENS BLVD
    Provider Second Line Business Practice Location Address: 
BLEULER PSYCHOTHERAY CENTER, SUITE 200
    Provider Business Practice Location Address City Name: 
FOREST HILLS
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11375-3638
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-275-6010
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/12/2014