Provider Demographics
NPI:1932337581
Name:BOMZER, PHILIP (PSYD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BOMZER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5-02 BRYANT PL
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5-02 BRYANT PL
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2175
Practice Address - Country:US
Practice Address - Phone:917-374-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020582103TC0700X, 103TM1800X
NJ35SI00543800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities