=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235254244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROCHEL SURICK DAVID PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 02/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 ENGLE ST 205
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-563-2831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 264 CHURCHILL RD
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-837-0238
-----------------------------------------------------
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 | 002212
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------