MEDICARE: DR. KIM ALTMAN WEISS 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	103TC0700X	Clinical Psychologist	04162	NJ
2	103TC0700X	Clinical Psychologist	013937	NY

General Provider Information

NPI Number	:	1265491328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM ALTMAN WEISS PH.D.

Provider Business Mailing Address
First Line	:	85 VAN BLARCOM LN
Second Line	:
City	:	WYCKOFF
State	:	NJ
Zip	:	07481-3443
Country	:	US
Telephone Number	:	201-378-7399
Fax Number	:

Provider Business Practice Location Address
First Line	:	65 N MAPLE AVE
Second Line	:	SUITE 301-C
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-3233
Country	:	US
Telephone Number	:	201-378-7399
Fax Number	:

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

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	07/08/2007

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