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General NPI Number Information
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NPI Number | 1841698131
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Entity Type | Organization
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Legal Business Name | J ROBERT QUILTY PHD PSYCHOLOGIST PC
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Dates
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Enumeration Date | 12/18/2014
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Last Update Date | 12/18/2014
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Provider Practice Location Address
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Address Line | 139 MAIN STREET
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City | STONY BROOK
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State | NY
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Zip | 11790-0304
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Country | US
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Telephone | 631-751-4873
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Fax | 631-473-8282
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Provider Business Mailing Address
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Address Line | PO BOX 304
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City | STONY BROOK
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State | NY
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Zip | 11790-0304
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Country | US
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Telephone | 631-751-4873
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Fax | 631-473-8282
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | ROBERT QUILTY
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Credential | PH.D.
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Telephone | 631-751-4873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 010801
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License Number State | NY
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