MEDICARE: JEPHTHA TAUSIG-EDWARDS 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	103T00000X	Psychologist	68-016753	NY
2	103TC0700X	Clinical Psychologist	68-016753	NY

General Provider Information

NPI Number	:	1407901630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEPHTHA TAUSIG-EDWARDS PH.D.

Provider Business Mailing Address
First Line	:	295 CENTRAL PARK W
Second Line	:	SUITE 2, OFFICE 1
City	:	NEW YORK
State	:	NY
Zip	:	10024-3008
Country	:	US
Telephone Number	:	212-595-9348
Fax Number	:

Provider Business Practice Location Address
First Line	:	295 CENTRAL PARK W
Second Line	:	SUITE 2, OFFICE 1
City	:	NEW YORK
State	:	NY
Zip	:	10024-3008
Country	:	US
Telephone Number	:	212-595-9348
Fax Number	:

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	09/26/2007

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