=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134259716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE NYFIELD PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 BROADWAY SUITE 201
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-751-1166
-----------------------------------------------------
Fax | 631-751-0889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 STURROCK WAY
-----------------------------------------------------
City | SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-751-1166
-----------------------------------------------------
Fax | 631-251-0889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 013459
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------