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General NPI Number Information
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NPI Number | 1518346733
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Entity Type | Organization
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Legal Business Name | PSYCHOTHERAPY PRIVATE PRACTICE
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Dates
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Enumeration Date | 05/20/2015
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Last Update Date | 05/20/2015
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Provider Practice Location Address
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Address Line | 166 ORCHARD ST 6D
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City | NEW YORK
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State | NY
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Zip | 10002-2282
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Country | US
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Telephone | 617-792-0264
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Fax |
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Provider Business Mailing Address
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Address Line | 166 ORCHARD ST 6D
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City | NEW YORK
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State | NY
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Zip | 10002-2282
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Country | US
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Telephone | 617-792-0264
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MIDORI PASION REPP
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Credential | LCSW
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Telephone | 617-792-0264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 079342
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License Number State | NY
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