=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194025445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSUMER PSYCHOLOGICAL SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2010
-----------------------------------------------------
Last Update Date | 11/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 OLD NYACK TPKE SUITE 601
-----------------------------------------------------
City | NANUET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10954-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-714-5023
-----------------------------------------------------
Fax | 845-634-0806
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 ZUKOR RD
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956-5507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-714-5023
-----------------------------------------------------
Fax | 845-634-0806
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LARRY S. BORAKOVE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 914-714-5023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 011044
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------