MEDICARE: GRAMERCY PSYCHOLOGICAL SERVICES LLC

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

General Provider Information

NPI Number	:	1831419019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAMERCY PSYCHOLOGICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	205 E 16TH ST
Second Line	:	SUITE M1A
City	:	NEW YORK
State	:	NY
Zip	:	10003-3746
Country	:	US
Telephone Number	:	212-696-7494
Fax Number	:	917-720-9022

Provider Business Practice Location Address
First Line	:	205 E 16TH ST
Second Line	:	SUITE M1A
City	:	NEW YORK
State	:	NY
Zip	:	10003-3746
Country	:	US
Telephone Number	:	212-696-7494
Fax Number	:	917-720-9022

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN CARROLL BERCK
Credential	:	PSYD
Telephone Number	:	212-696-7494

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	06/10/2010

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