Basic Information
| Provider Information | |||||||||
| NPI: | 1720099906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWEY | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 24TH AVE | ||||||||
| Address2: | 2A | ||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111022337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182166664 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 W END AVE | ||||||||
| Address2: | 1C | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100253533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518100 | ||||||||
| FaxNumber: | 2129320934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 16405 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02812173 | 05 | NY | MEDICAID |