MEDICARE: DIJANA BLACIC 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	103TC0700X	Clinical Psychologist	016908-1	NY

General Provider Information

NPI Number	:	1669555389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIJANA BLACIC PSYD

Provider Business Mailing Address
First Line	:	160 HOWELLS RD STE 2
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5320
Country	:	US
Telephone Number	:	631-647-7885
Fax Number	:	631-647-7893

Provider Business Practice Location Address
First Line	:	160 HOWELLS RD STE 2
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-5320
Country	:	US
Telephone Number	:	631-647-7885
Fax Number	:	631-647-7893

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	09/04/2007

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