Healthcare Provider Details

I. General information

NPI: 1043921638
Provider Name (Legal Business Name): VIRATRI PHONROME PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NOYES ST
UTICA NY
13502-3852
US

IV. Provider business mailing address

46 CHERRYWOOD LN
ROME NY
13440-4772
US

V. Phone/Fax

Practice location:
  • Phone: 315-738-4439
  • Fax: 315-738-4450
Mailing address:
  • Phone: 202-344-5718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number025308
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: