Basic Information
| Provider Information | |||||||||
| NPI: | 1720037427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | R.G. PSYCHOLOGICAL SERVICES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 MERRICK RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LYNBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115632501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007256280 | ||||||||
| FaxNumber: | 8007256380 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 MERRICK RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LYNBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115632501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007256280 | ||||||||
| FaxNumber: | 8007256380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | LABRUZZO | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8007256280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 01615874 | 05 | NY | MEDICAID |