MEDICARE: DOWNTOWN BROOKLYN THERAPY

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	020970	NY

General Provider Information

NPI Number	:	1902278815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNTOWN BROOKLYN THERAPY

Provider Business Mailing Address
First Line	:	26 COURT ST STE 1304
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11242-1113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 COURT ST STE 1304
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11242-1113
Country	:	US
Telephone Number	:	347-915-4168
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. SUMITHRA RAGHAVAN
Credential	:	PHD
Telephone Number	:	347-915-4168

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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