Provider Demographics
NPI:1609042621
Name:PARK SLOPE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:PARK SLOPE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-275-3243
Mailing Address - Street 1:319 18TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6109
Mailing Address - Country:US
Mailing Address - Phone:917-545-7503
Mailing Address - Fax:800-275-3671
Practice Address - Street 1:319 18TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-6109
Practice Address - Country:US
Practice Address - Phone:917-545-7503
Practice Address - Fax:800-275-3671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016099-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02726185Medicaid
NY02726185Medicaid