=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417292541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID J BLANK PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 N STATE RD
-----------------------------------------------------
City | BRIARCLIFF MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10510-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-773-6115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 HOWE ST
-----------------------------------------------------
City | SOUTH SALEM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10590-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-579-9335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 019576
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------