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General NPI Number Information
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NPI Number | 1225474968
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Entity Type | Organization
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Legal Business Name | LONG ISLAND GERIATRIC PSYCHOLOGICAL SERVICES P.C.
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Dates
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Enumeration Date | 05/21/2013
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Last Update Date | 05/21/2013
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Provider Practice Location Address
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Address Line | 118-35 QUEENS BLVD SUITE 1403
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City | FOREST HILLS
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State | NY
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Zip | 11375-7205
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Country | US
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Telephone | 718-268-6600
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Fax |
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Provider Business Mailing Address
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Address Line | 118-35 QUEENS BLVD SUITE 1403
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City | FOREST HILLS
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State | NY
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Zip | 11375-7205
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Country | US
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Telephone | 718-268-6600
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUSAN J HALL
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Credential | PH.D.
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Telephone | 718-268-6600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 015238-1
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License Number State | NY
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