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General NPI Number Information
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NPI Number | 1568904639
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Entity Type | Organization
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Legal Business Name | NY WELLNESS PSYCHOLOGY PC
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Dates
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Enumeration Date | 11/07/2016
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 250 E 30TH ST APT 9A
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City | NEW YORK
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State | NY
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Zip | 10016-8298
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Country | US
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Telephone | 631-786-9312
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Fax |
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Provider Business Mailing Address
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Address Line | 466 W 153RD ST
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City | NEW YORK
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State | NY
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Zip | 10031-1101
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Country | US
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Telephone | 631-786-9312
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/DIRECTOR
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Name | DR. SHIBANI RAY-MAZUMDER
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Credential | PH.D, SC.D
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Telephone | 631-786-9312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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License Number | 020691-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 02069-1
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License Number State | NY
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