Provider Demographics
NPI:1811948441
Name:SCHORK, EDWARD JOSEPH JR (PHD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:SCHORK
Suffix:JR
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 1:34 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5361
Mailing Address - Country:US
Mailing Address - Phone:203-448-9742
Mailing Address - Fax:
Practice Address - Street 1:523 E PUTNAM AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4877
Practice Address - Country:US
Practice Address - Phone:203-448-9742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008855103TC0700X, 103TB0200X
CT001636103TC0700X, 103TC2200X, 103TB0200X
NY08855103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01802088Medicaid
NYV8C072Medicare PIN