=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255941894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ML PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2020
-----------------------------------------------------
Last Update Date | 08/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 OLD MAMARONECK RD
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-838-2952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 OLD MAMARONECK RD
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MELISSA LARACUENTA
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 646-838-2952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------