Provider Demographics
NPI:1417260571
Name:PSYCHOLOGICAL SERVICES FOR SELF AND FAMILY, PLLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICES FOR SELF AND FAMILY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-637-9131
Mailing Address - Street 1:523 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1536
Mailing Address - Country:US
Mailing Address - Phone:315-637-9131
Mailing Address - Fax:315-637-9151
Practice Address - Street 1:523 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1536
Practice Address - Country:US
Practice Address - Phone:315-637-9131
Practice Address - Fax:315-637-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009823-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty