Provider Demographics
NPI:1841642949
Name:ALCANTAR-HEREDIA, JORGE LUIS (PSYD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:ALCANTAR-HEREDIA
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 1:245 E 19TH ST APT 18A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2662
Mailing Address - Country:US
Mailing Address - Phone:805-540-1555
Mailing Address - Fax:
Practice Address - Street 1:245 E 19TH ST APT 18A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2662
Practice Address - Country:US
Practice Address - Phone:805-540-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical