MEDICARE: ELLEN TOBEY KLASS PH.D.

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	103TB0200X	Cognitive & Behavioral Psychologist	PSY 5042	NY
2	103TC0700X	Clinical Psychologist	PSY 5042	NY

General Provider Information

NPI Number	:	1154629517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN TOBEY KLASS PH.D.

Provider Business Mailing Address
First Line	:	40 W 17TH ST
Second Line	:	3A
City	:	NEW YORK
State	:	NY
Zip	:	10011-5715
Country	:	US
Telephone Number	:	212-242-0132
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 W 17TH ST
Second Line	:	3A
City	:	NEW YORK
State	:	NY
Zip	:	10011-5715
Country	:	US
Telephone Number	:	212-242-0132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2011
Last Update Date	:	03/09/2011

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