Basic Information
| Provider Information | |||||||||
| NPI: | 1457302648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARD | ||||||||
| FirstName: | BEVERLY | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1156 N BROADWAY | ||||||||
| Address2: | ANDRUS CHILDREN'S CENTER | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107011108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149653700 | ||||||||
| FaxNumber: | 9149653883 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 GREENRIDGE AVE | ||||||||
| Address2: | ANDRUS CHILDREN'S CENTER MENTAL HEALTH DIVISION | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149497680 | ||||||||
| FaxNumber: | 9149977942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 010243 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00355940 | 05 | NY | MEDICAID | 010243 | 01 | NY | NYS PHD LICENSE # | OTHER | 1285628552 | 01 | NY | JDAM NPI # | OTHER |