Provider Demographics
NPI:1487023685
Name:BACON, JOSHUA (PHD)
Entity Type:Individual
Prefix:PROF
First Name:JOSHUA
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E 38TH ST FL 18
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2708
Mailing Address - Country:US
Mailing Address - Phone:646-501-7502
Mailing Address - Fax:646-754-9593
Practice Address - Street 1:240 E 38TH ST FL 18
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2708
Practice Address - Country:US
Practice Address - Phone:646-501-7502
Practice Address - Fax:646-754-9593
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014205103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral