=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508134321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | XUE JIE MA PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2011
-----------------------------------------------------
Last Update Date | 12/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 WICKS DRIVE
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-271-5637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 WICKS DRIVE
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-908-8960
-----------------------------------------------------
Fax | 631-486-7514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 015290
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------