=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053768424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COHEN PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 11/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 BRADLEY AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-5166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-558-3010
-----------------------------------------------------
Fax | 516-558-3011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 E SUNRISE HIGHWAY SUITE 500 #6409
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-558-3010
-----------------------------------------------------
Fax | 516-558-3011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELIE COHEN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 516-558-3010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 020858
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------