Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 022047-1 | NY |
Y | 103T00000X | Psychologist | 022047-1 | NY |
NPI | 1013457431 |
---|---|
Provider Name | Mark Terjesen |
First Address | Glen Cove, NY 11542-4032 |
Second Address | Jamaica, NY 11439-9000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/03/2017 |
Last Update Date | 04/03/2017 |