Healthcare Provider Details

I. General information

NPI: 1922632769
Provider Name (Legal Business Name): NURI ERKUT KUCUKBOYACI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 QUENTIN RD STE 110
BROOKLYN NY
11234-4245
US

IV. Provider business mailing address

24 KEW DR
SPRINGFIELD NJ
07081-2505
US

V. Phone/Fax

Practice location:
  • Phone: 800-275-3243
  • Fax:
Mailing address:
  • Phone: 617-230-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number023781
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number023781
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number023781
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number023781
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: