Provider Demographics
NPI:1730465063
Name:KRELLMAN, JASON (PHD, ABPP-CN)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:KRELLMAN
Suffix:
Gender:M
Credentials:PHD, ABPP-CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3726
Mailing Address - Country:US
Mailing Address - Phone:646-426-3876
Mailing Address - Fax:212-305-1145
Practice Address - Street 1:710 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3726
Practice Address - Country:US
Practice Address - Phone:646-426-3876
Practice Address - Fax:212-305-1145
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019043103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist