Provider Demographics
NPI:1821257460
Name:PSYCHOLOGICAL & FAMILY SERVICES
Entity Type:Organization
Organization Name:PSYCHOLOGICAL & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:WILETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-472-9042
Mailing Address - Street 1:500 N MCBRIDE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1913
Mailing Address - Country:US
Mailing Address - Phone:315-472-9042
Mailing Address - Fax:315-472-9065
Practice Address - Street 1:500 N MCBRIDE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1913
Practice Address - Country:US
Practice Address - Phone:315-472-9042
Practice Address - Fax:315-472-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005499-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52957AMedicare PIN