Healthcare Provider Details

I. General information

NPI: 1326659988
Provider Name (Legal Business Name): MS. HENRIETTA U. ILOMUDIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 N PLANK RD STE 10
NEWBURGH NY
12550-2111
US

IV. Provider business mailing address

1176 E 223RD ST
BRONX NY
10466-5833
US

V. Phone/Fax

Practice location:
  • Phone: 845-800-9305
  • Fax:
Mailing address:
  • Phone: 718-344-3382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: