Provider Demographics
NPI:1659627206
Name:SURBAUGH PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:SURBAUGH PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SURBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:917-974-6733
Mailing Address - Street 1:31 WASHINGTON SQ W
Mailing Address - Street 2:SUITE 5R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-9126
Mailing Address - Country:US
Mailing Address - Phone:917-974-6733
Mailing Address - Fax:
Practice Address - Street 1:31 WASHINGTON SQ W
Practice Address - Street 2:SUITE 5R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-9126
Practice Address - Country:US
Practice Address - Phone:917-974-6733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty