Healthcare Provider Details

I. General information

NPI: 1902235914
Provider Name (Legal Business Name): BRONX INDIVIDUAL & FAMILY PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 E KINGSBRIDGE RD
BRONX NY
10468-7596
US

IV. Provider business mailing address

22 E KINGSBRIDGE RD
BRONX NY
10468-7596
US

V. Phone/Fax

Practice location:
  • Phone: 917-801-1199
  • Fax: 917-801-1198
Mailing address:
  • Phone: 917-801-1199
  • Fax: 917-801-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number102065
License Number StateNY

VIII. Authorized Official

Name: DR. MARIA LYDIA VAYAS
Title or Position: MANAGING MEMBER (PSYCHOLOGIST)
Credential: PSY.D
Phone: 917-801-1199