=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508680240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SQUARE ONE PSYCHOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 W 58TH ST STE 409
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-419-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 W 58TH ST STE 409
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-419-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, DIRECTOR OF CLINICAL SERVICE
-----------------------------------------------------
Name | ZOHRA CHAHAL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 646-419-8550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------