Healthcare Provider Details

I. General information

NPI: 1295125110
Provider Name (Legal Business Name): QUEENS COGNITIVE BEHAVIORAL THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14108 JEWEL AVE
FLUSHING NY
11367-1618
US

IV. Provider business mailing address

14108 JEWEL AVE
FLUSHING NY
11367-1618
US

V. Phone/Fax

Practice location:
  • Phone: 347-815-4228
  • Fax: 413-639-4458
Mailing address:
  • Phone: 347-815-4228
  • Fax: 413-639-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number019732
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number019732
License Number StateNY

VIII. Authorized Official

Name: DR. BENJAMIN ZVI GRYSMAN
Title or Position: DIRECTOR, PSYCHOLOGIST
Credential: PH.D.
Phone: 347-815-4228