=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407911902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL THISTLETHWAITE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 5TH AVE SUITE 720
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-7002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-337-9596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 E 7TH ST APT. C-12
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-6203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-982-5247
-----------------------------------------------------
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 | 007451
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------