Healthcare Provider Details

I. General information

NPI: 1871000786
Provider Name (Legal Business Name): JONATHAN DESMOND MCRAE M.S. ED., CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 COOPER HILL RD
WYNANTSKILL NY
12198-2906
US

IV. Provider business mailing address

611 WARREN ST
ALBANY NY
12208-3215
US

V. Phone/Fax

Practice location:
  • Phone: 518-283-6500
  • Fax: 518-283-7156
Mailing address:
  • Phone: 914-318-8367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1135610171
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: