=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386069219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANASTASIA RAISA PYTAL PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2014
-----------------------------------------------------
Last Update Date | 09/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 EAST MAIN STREET, 2ND FLOOR
-----------------------------------------------------
City | LITTLE FALLS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07424-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-454-5569
-----------------------------------------------------
Fax | 856-423-0823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 W COHAWKIN RD STE C
-----------------------------------------------------
City | CLARKSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08020-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-423-7700
-----------------------------------------------------
Fax | 856-423-0823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 0810004880
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 708895
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 8355061
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 5288
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY1000880
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------