MEDICARE: CAROLE A SRINIVASAN 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	016793	NY

General Provider Information

NPI Number	:	1417970781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE A SRINIVASAN PH.D.

Provider Business Mailing Address
First Line	:	151 INWOOD AVE
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07043-1906
Country	:	US
Telephone Number	:	917-297-6618
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 W 73RD ST
Second Line	:	SUITE 101
City	:	NEW YORK
State	:	NY
Zip	:	10023-3104
Country	:	US
Telephone Number	:	917-282-8461
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/10/2012

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