MEDICARE: QUEENS COGNITIVE BEHAVIORAL THERAPY CENTER

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	019732	NY
2	103T00000X	Psychologist	019732	NY

General Provider Information

NPI Number	:	1295125110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEENS COGNITIVE BEHAVIORAL THERAPY CENTER

Provider Business Mailing Address
First Line	:	14108 JEWEL AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1618
Country	:	US
Telephone Number	:	347-815-4228
Fax Number	:	413-639-4458

Provider Business Practice Location Address
First Line	:	14108 JEWEL AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1618
Country	:	US
Telephone Number	:	347-815-4228
Fax Number	:	413-639-4458

Authorized Official
Title or Position	:	DIRECTOR, PSYCHOLOGIST
Name	:	DR. BENJAMIN ZVI GRYSMAN
Credential	:	PH.D.
Telephone Number	:	347-815-4228

Provider Enumeration Date	:	01/30/2015
Last Update Date	:	01/30/2015

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