Healthcare Provider Details

I. General information

NPI: 1679949036
Provider Name (Legal Business Name): PROFESSIONAL CONSULTATION SERVICES FOR PSYCHOLOGY,SPEECH THERAPY, OCCU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 NORTH AVE SUITE 111
NEW ROCHELLE NY
10801-5104
US

IV. Provider business mailing address

271 NORTH AVE SUITE 111
NEW ROCHELLE NY
10801-5104
US

V. Phone/Fax

Practice location:
  • Phone: 914-235-3674
  • Fax:
Mailing address:
  • Phone: 914-235-3674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JON MICHNOVICZ
Title or Position: NOMINEE OWNER
Credential:
Phone: 516-246-4893