Healthcare Provider Details

I. General information

NPI: 1255499976
Provider Name (Legal Business Name): NIJOLE KUDIRKA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 IRVING PL 1A
NEW YORK NY
10003
US

IV. Provider business mailing address

78 IRVING PL 1A
NEW YORK NY
10003
US

V. Phone/Fax

Practice location:
  • Phone: 212-254-2150
  • Fax:
Mailing address:
  • Phone: 212-254-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003412
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: