Basic Information
| Provider Information | |||||||||
| NPI: | 1407461031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URSILLO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E STEVENS AVE STE LL5 | ||||||||
| Address2: | |||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144507926 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 529 COURTLANDT AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104515007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189937700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 013010-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 013010-1 | 05 | NY | MEDICAID |