=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497814933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENIORSTAT PSYCHIATRIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2006
-----------------------------------------------------
Last Update Date | 10/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 891 NORTHERN BLVD STE 201
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-829-5483
-----------------------------------------------------
Fax | 516-829-5403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 SUNSET RD S
-----------------------------------------------------
City | ALBERTSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11507-1149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-604-5037
-----------------------------------------------------
Fax | 718-363-6630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NANCY TALAVERA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-604-5037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------