=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174834352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AYXA CALERO-BRECKHEIMER PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2010
-----------------------------------------------------
Last Update Date | 06/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 W END AVE SUITE 3Y
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-435-6498
-----------------------------------------------------
Fax | 646-476-9814
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 PAULIN BLVD
-----------------------------------------------------
City | LEONIA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07605-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-585-0757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 018429-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------