Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 35SI00554300 | NJ |
Y | 103TC0700X | Clinical Psychologist | 35SI00554300 | NJ |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 35SI00554300 | NJ |
NPI | 1073821351 |
---|---|
Provider Name | Dr. Blake Evan Kirschner |
First Address | Montclair, NJ 07042-4420 |
Second Address | Montclair, NJ 07042-4420 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2010 |
Last Update Date | 19/12/2015 |