Healthcare Provider Details

I. General information

NPI: 1790483766
Provider Name (Legal Business Name): EC PSYCHIATRIC NURSE PRACTITIONER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ROBIN HOOD RD
SUFFERN NY
10901-3820
US

IV. Provider business mailing address

115 FRANKLIN TURNPIKE PO BOX 168
MAHWAH NJ
07430
US

V. Phone/Fax

Practice location:
  • Phone: 646-671-1187
  • Fax:
Mailing address:
  • Phone: 646-671-1187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EDNER CUVILLY
Title or Position: NURSE PRACTITIONER PSYCHIATRY
Credential: NPP
Phone: 646-671-1187