Healthcare Provider Details

I. General information

NPI: 1841426665
Provider Name (Legal Business Name): BERTRAM OLIVER PLOOG PH.D., BCBA-D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 SAINT MARKS PL
STATEN ISLAND NY
10301-1607
US

IV. Provider business mailing address

56 SAINT MARKS PL
STATEN ISLAND NY
10301-1607
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-4083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number000065-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number021285
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: