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General NPI Number Information
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NPI Number | 1902198302
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Entity Type | Individual
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Provider Name | BRENT IVAN BOUNDS PHD
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Gender | Male
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 05/04/2011
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Provider Practice Location Address
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Address Line | 276 5TH AVE STE 507B.6
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City | NEW YORK
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State | NY
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Zip | 10001-4509
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Country | US
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Telephone | 646-455-3539
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Fax |
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Provider Business Mailing Address
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Address Line | 149 W 95TH ST APT A
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City | NEW YORK
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State | NY
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Zip | 10025-6650
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Country | US
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Telephone | 917-833-7935
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 019071
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License Number State | NY
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