Provider Demographics
NPI:1902198302
Name:BOUNDS, BRENT IVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:IVAN
Last Name:BOUNDS
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 1:149 W 95TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6650
Mailing Address - Country:US
Mailing Address - Phone:917-833-7935
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE STE 507B.6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4509
Practice Address - Country:US
Practice Address - Phone:646-455-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical