Healthcare Provider Details

I. General information

NPI: 1932134087
Provider Name (Legal Business Name): EDWARD JOHN BARNOSKI PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MEDFORD AVE STE D
PATCHOGUE NY
11772-1230
US

IV. Provider business mailing address

77 MEDFORD AVE STE D
PATCHOGUE NY
11772-1230
US

V. Phone/Fax

Practice location:
  • Phone: 631-366-3369
  • Fax: 631-366-3369
Mailing address:
  • Phone: 631-366-3369
  • Fax: 631-366-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number011687-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number011687-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01503557
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: