=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477965978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW YORK PSYCHOLOGICAL WELLNESS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2014
-----------------------------------------------------
Last Update Date | 06/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4640 SPRINGFIELD BLVD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-225-5505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4640 SPRINGFIELD BLVD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-225-5505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. ROBERT S. MEYERS
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 718-225-5505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 018595
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------