MEDICARE: RIVER BEND PSYCHOLOGICAL SERVICES, 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	1041C0700X	Clinical Social Worker		NY
2	103T00000X	Psychologist		NY

General Provider Information

NPI Number	:	1568622785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER BEND PSYCHOLOGICAL SERVICES, PC

Provider Business Mailing Address
First Line	:	23 CONVER DR
Second Line	:
City	:	SARATOGA SPRINGS
State	:	NY
Zip	:	12866-9740
Country	:	US
Telephone Number	:	518-580-9863
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 CONVER DR
Second Line	:
City	:	SARATOGA SPRINGS
State	:	NY
Zip	:	12866-9740
Country	:	US
Telephone Number	:	518-580-9863
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	JOHATHAN SULKIN
Credential	:	PHD
Telephone Number	:	518-580-9863

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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