Healthcare Provider Details

I. General information

NPI: 1568904639
Provider Name (Legal Business Name): NY WELLNESS PSYCHOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 09/08/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E 30TH ST APT 9A
NEW YORK NY
10016-8298
US

IV. Provider business mailing address

466 W 153RD ST
NEW YORK NY
10031-1101
US

V. Phone/Fax

Practice location:
  • Phone: 631-786-9312
  • Fax:
Mailing address:
  • Phone: 631-786-9312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number020691-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number02069-1
License Number StateNY

VIII. Authorized Official

Name: DR. SHIBANI RAY-MAZUMDER
Title or Position: CLINICAL PSYCHOLOGIST/DIRECTOR
Credential: PH.D, SC.D
Phone: 631-786-9312