Healthcare Provider Details

I. General information

NPI: 1427136704
Provider Name (Legal Business Name): AUDRA YACKA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SENIOR ST
NEW BRUNSWICK NJ
08901-8534
US

IV. Provider business mailing address

17 SENIOR ST
NEW BRUNSWICK NJ
08901-8534
US

V. Phone/Fax

Practice location:
  • Phone: 732-932-7884
  • Fax:
Mailing address:
  • Phone: 732-932-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35SI00422100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: