=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184812513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALA DATTA PH.,D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2007
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 294-298 STATE ST STE 1
-----------------------------------------------------
City | HACKENSACK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07601-5544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-9905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 259 MASSACHUSETTS AVE STE 1
-----------------------------------------------------
City | HAWORTH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07641-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-9905
-----------------------------------------------------
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 | 35S100543600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 012711
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 01271101
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------