MEDICARE: NEW YORK STATE PSYCHIATRIC INSTITUTE

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	283Q00000X	Psychiatric Hospital	006354-1	NY

General Provider Information

NPI Number	:	1740599570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW YORK STATE PSYCHIATRIC INSTITUTE

Provider Business Mailing Address
First Line	:	504 W 136TH ST
Second Line	:	APT 6-C
City	:	NEW YORK
State	:	NY
Zip	:	10031-7908
Country	:	US
Telephone Number	:	164-662-3779
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 W 136TH ST
Second Line	:	APT 6-C
City	:	NEW YORK
State	:	NY
Zip	:	10031-7908
Country	:	US
Telephone Number	:	164-662-3779
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPY ASSISTANT
Name	:	MR. HERIBERTO RIVERA
Credential	:	CERTIFIED
Telephone Number	:	164-662-3779

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	09/28/2010

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