MEDICARE: RIDGE PSYCHOLOGICAL SERVICES PLLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1922596543
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGE PSYCHOLOGICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	446 74TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-2602
Country	:	US
Telephone Number	:	917-921-0704
Fax Number	:

Provider Business Practice Location Address
First Line	:	446 74TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-2602
Country	:	US
Telephone Number	:	917-921-0704
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER/PSYCHOLOGIST
Name	:	DEBORAH DE SANTIS-MONIACI
Credential	:	PHD
Telephone Number	:	917-921-0704

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	04/30/2018

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