Healthcare Provider Details

I. General information

NPI: 1124762455
Provider Name (Legal Business Name): INTEGRATIVE PSYCHOLOGICAL PROFESSIONAL SERVICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E EVERGREEN RD
NEW CITY NY
10956-5101
US

IV. Provider business mailing address

2 NELSON LN
CONGERS NY
10920-1109
US

V. Phone/Fax

Practice location:
  • Phone: 845-579-5728
  • Fax: 845-845-3357
Mailing address:
  • Phone: 718-541-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHANELLE RICHARDS
Title or Position: OWNER/PSYCHOLOGIST
Credential: PHD
Phone: 845-579-5728