=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720522139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2016
-----------------------------------------------------
Last Update Date | 09/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 E 39TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-580-8866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 E 39TH ST STE 800
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-580-8866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | INDIANA GOULD BUTTENWIESER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 646-580-8866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 021507
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------