MEDICARE: DR. ANASTASIA RAISA PYTAL PSYD

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	0810004880	VA
2	103T00000X	Psychologist	708895	MD
3	103T00000X	Psychologist	8355061	NY
4	103T00000X	Psychologist	5288	NJ
5	103T00000X	Psychologist	PSY1000880	DC

General Provider Information

NPI Number	:	1386069219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANASTASIA RAISA PYTAL PSYD

Provider Business Mailing Address
First Line	:	175 W COHAWKIN RD STE C
Second Line	:
City	:	CLARKSBORO
State	:	NJ
Zip	:	08020-1145
Country	:	US
Telephone Number	:	856-423-7700
Fax Number	:	856-423-0823

Provider Business Practice Location Address
First Line	:	39 EAST MAIN STREET, 2ND FLOOR
Second Line	:
City	:	LITTLE FALLS
State	:	NJ
Zip	:	07424-2206
Country	:	US
Telephone Number	:	973-454-5569
Fax Number	:	856-423-0823

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

Provider Enumeration Date	:	03/01/2014
Last Update Date	:	09/23/2019

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