Provider Demographics
NPI:1639709439
Name:WELLNESS ROAD PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:WELLNESS ROAD PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:646-961-4973
Mailing Address - Street 1:15 N ECKAR ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-1510
Mailing Address - Country:US
Mailing Address - Phone:914-671-4860
Mailing Address - Fax:
Practice Address - Street 1:140 BROADWAY # 4657
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-1108
Practice Address - Country:US
Practice Address - Phone:646-961-4973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty