Provider Demographics
NPI:1538837414
Name:IMPACT PSYCHOLOGICAL SERVICES PLLC
Entity type:Organization
Organization Name:IMPACT PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROUT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:917-596-2958
Mailing Address - Street 1:1183 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-1700
Mailing Address - Country:US
Mailing Address - Phone:917-596-2958
Mailing Address - Fax:
Practice Address - Street 1:1183 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-1700
Practice Address - Country:US
Practice Address - Phone:917-300-1332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health