=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407870348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA CHAN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 05/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 W 56TH ST STE 1804
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-3878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-851-8102
-----------------------------------------------------
Fax | 888-977-2547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 OLD STONE HILL RD
-----------------------------------------------------
City | POUND RIDGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10576-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-748-8709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 16515
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------