MEDICARE: AWARENESS PSYCHOLOGICAL HEALTH AND GROWTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	8090-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V5332	OTHER	NY	EMPIRE BLUE CROSS
2	058472	OTHER	NY	VALUE OPTIONS
3	81182000	OTHER	NY	MAGELLAN BEHAVIORAL HEALT

General Provider Information

NPI Number	:	1851517270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWARENESS PSYCHOLOGICAL HEALTH AND GROWTH SERVICES

Provider Business Mailing Address
First Line	:	125 PLEASANT ST APT 609
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02446-7183
Country	:	US
Telephone Number	:	617-277-1961
Fax Number	:

Provider Business Practice Location Address
First Line	:	1394 STONY BROOK RD
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2205
Country	:	US
Telephone Number	:	617-429-8049
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. RIVCKA EDELSTEIN
Credential	:	PHD
Telephone Number	:	617-429-8049

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	08/22/2020

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