=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710239025
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLRHC FACULTY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2012
-----------------------------------------------------
Last Update Date | 10/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 AMSTERDAM AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-523-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 W 57TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-523-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | DEBORAH HACKETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-256-3424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------