| NPI | 1093011413 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIM JACKSON Director 646-571-8627 |
| Organization Subpart ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: IL 071-005431) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MD 03127) |
| 103T00000X Psychologist (Licence: WI 2592-057) | |
| 103TC0700X Psychologist, Clinical (Licence: HI 1214) | |
| 1041C0700X Social Worker, Clinical (Licence: CA MFT (MFC) 37695) | |
| Enumeration Date | 2011-02-02 |
| Last Update Date | 2011-02-02 |