=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033128749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN Y CHAN PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 198 CANAL STREET SUITE 504-505
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-233-2223
-----------------------------------------------------
Fax | 201-313-4467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 E COLUMBIA AVE UNIT A
-----------------------------------------------------
City | PALISADES PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07650-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-313-3365
-----------------------------------------------------
Fax | 201-313-4467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 005566
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------