=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205840584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA BUSCH SOMACH PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3930 RICHMOND AVE SUITE 104
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-605-6383
-----------------------------------------------------
Fax | 718-605-6384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 VINCENT AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10306-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-605-6383
-----------------------------------------------------
Fax | 718-605-6384
-----------------------------------------------------
=====================================================
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 | 012048
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------