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General NPI Number Information
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NPI Number | 1508098732
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Entity Type | Organization
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Legal Business Name | NEW YORK BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 08/21/2009
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Last Update Date | 08/21/2009
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Provider Practice Location Address
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Address Line | 909 3RD AVE SUITE 505
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City | NEW YORK
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State | NY
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Zip | 10022-4731
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Country | US
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Telephone | 646-495-3078
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Fax |
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Provider Business Mailing Address
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Address Line | 909 3RD AVE
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City | NEW YORK
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State | NY
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Zip | 10022-4731
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Country | US
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Telephone | 646-495-3078
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. J. RYAN FULLER
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Credential | PH.D.
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Telephone | 646-495-3078
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 017620
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License Number State | NY
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