Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2084P0804X | Psychiatry & Neurology | Child & Adolescent Psychiatry | | | No |
| 2 | 101YM0800X | Counselor | Mental Health | | | No |
| 3 | 363LP0808X | Nurse Practitioner | Psychiatric/Mental Health | NYF30339-1 | NEW YORK | No |
| 4 | 261QM0850X | Clinic/Center | Adult Mental Health | | | No |
| 5 | 261QM0855X | Clinic/Center | Adolescent and Children Mental Health | | | No |
| 6 | 251S00000X | Community/Behavioral Health | | | | No |
| 7 | 103TC0700X | Psychologist | Clinical | 6952100A | NEW YORK | No |
| 8 | 261QM0801X | Clinic/Center | Mental Health (Including Community Mental Health Center) | | | No |
| 9 | 2084P0800X | Psychiatry & Neurology | Psychiatry | 238550-1 | NEW YORK | No |
| 10 | 1041C0700X | Social Worker | Clinical | 6952100A | NEW YORK | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 00562890 | MEDICAID | NEW YORK | |
| 2 | 02997464 | MEDICAID | NEW YORK | |
| 3 | 041108000114 | OTHER | NEW YORK | FIDELLAS PROVIDER ID# |
| 4 | 000158890 | OTHER | NEW YORK | EXCELLUS PROVIDER ID# |
