=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801019724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS RADCLIFFE PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 585 N BARRY AVE
-----------------------------------------------------
City | MAMARONECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10543-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-473-1474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 CHESTER PL
-----------------------------------------------------
City | LARCHMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10538-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-576-4881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 015286
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------