=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992471130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC I EHRLICH PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2021
-----------------------------------------------------
Last Update Date | 08/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | FUENTE DE ETIOPIA 27 LOMAS DE TECAMACHALCO
-----------------------------------------------------
City | HUIXQUILUCAN
-----------------------------------------------------
State | ESTADO DE MEXICO
-----------------------------------------------------
Zip | 52780
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone | 559-199-6530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | FUENTE DE ETIOPIA #27
-----------------------------------------------------
City | LOMAS DE TECAMACHALCO
-----------------------------------------------------
State | HUIXQUILUCAN
-----------------------------------------------------
Zip | 52780
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 009325
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------