Provider Demographics
NPI:1013694785
Name:TRUJILLO, MARCEL RYAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARCEL
Middle Name:RYAN
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 21ST ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3681
Mailing Address - Country:US
Mailing Address - Phone:914-996-8377
Mailing Address - Fax:
Practice Address - Street 1:2125 21ST ST APT 2
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3681
Practice Address - Country:US
Practice Address - Phone:914-996-8377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP111673390200000X
NY026049103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program