Healthcare Provider Details

I. General information

NPI: 1811948441
Provider Name (Legal Business Name): EDWARD JOSEPH SCHORK JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 E PUTNAM AVE SUITE 24
GREENWICH CT
06830-4877
US

IV. Provider business mailing address

34 SLEEPY HOLLOW DR
DANBURY CT
06810-5361
US

V. Phone/Fax

Practice location:
  • Phone: 203-448-9742
  • Fax:
Mailing address:
  • Phone: 203-448-9742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number001636
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number008855
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number008855
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number001636
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number001636
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number08855
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: