MEDICARE: NEW YORK PSYCHOLOGICAL PRACTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1063060887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW YORK PSYCHOLOGICAL PRACTICE

Provider Business Mailing Address
First Line	:	979 LAMONT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-2207
Country	:	US
Telephone Number	:	347-524-4169
Fax Number	:	718-565-5070

Provider Business Practice Location Address
First Line	:	979 LAMONT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-2207
Country	:	US
Telephone Number	:	347-524-4169
Fax Number	:	718-565-5070

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. VIRGINIA BOGA
Credential	:	PH.D.
Telephone Number	:	347-524-4169

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	08/27/2019

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