Provider Demographics
NPI:1437614328
Name:SELF REFLECTION PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:SELF REFLECTION PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:SELF REFLECTION PSYCHOLOGICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ-VELEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:347-922-4574
Mailing Address - Street 1:47 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-5126
Mailing Address - Country:US
Mailing Address - Phone:347-922-4574
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4038
Practice Address - Country:US
Practice Address - Phone:347-922-4574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)