=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396071825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY CENTER FOR BEHAVIORAL HEALTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2009
-----------------------------------------------------
Last Update Date | 03/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 287 NORTHERN BLVD SUITE 100
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-4717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-487-4202
-----------------------------------------------------
Fax | 201-692-0234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 287 NORTHERN BLVD SUITE 100
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-4717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-487-4202
-----------------------------------------------------
Fax | 201-692-0234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | MARTIN KLUGER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 516-487-4202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 10139
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------