Healthcare Provider Details

I. General information

NPI: 1588840201
Provider Name (Legal Business Name): JEPHTHA TAUSIG-EDWARDS, PHD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 CENTRAL PARK W SUITE 2
NEW YORK NY
10024-3008
US

IV. Provider business mailing address

295 CENTRAL PARK W SUITE 2
NEW YORK NY
10024-3008
US

V. Phone/Fax

Practice location:
  • Phone: 212-595-9348
  • Fax:
Mailing address:
  • Phone: 212-595-9348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number016753-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number016753-1
License Number StateNY

VIII. Authorized Official

Name: DR. JEPHTHA TAUSIG-EDWARDS
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 212-595-9348