MEDICARE: NEW YORK PSYCHOLOGICAL WELLNESS, PC

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	018595	NY

General Provider Information

NPI Number	:	1477965978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW YORK PSYCHOLOGICAL WELLNESS, PC

Provider Business Mailing Address
First Line	:	4640 SPRINGFIELD BLVD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3517
Country	:	US
Telephone Number	:	718-225-5505
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 SPRINGFIELD BLVD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3517
Country	:	US
Telephone Number	:	718-225-5505
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ROBERT S. MEYERS
Credential	:	PSYD
Telephone Number	:	718-225-5505

Provider Enumeration Date	:	06/02/2014
Last Update Date	:	06/02/2014

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