Healthcare Provider Details

I. General information

NPI: 1730404740
Provider Name (Legal Business Name): MARY JOSEPH KOLLAPPALLIL PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15011 HILLSIDE AVE 2ND FLOOR
JAMAICA NY
11432-3319
US

IV. Provider business mailing address

15011 HILLSIDE AVE 2ND FLOOR
JAMAICA NY
11432-3319
US

V. Phone/Fax

Practice location:
  • Phone: 718-739-5778
  • Fax: 718-523-2728
Mailing address:
  • Phone: 718-739-5778
  • Fax: 718-523-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number017693
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: