EFTA00602690

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Kamran Fallahpour, PhD 263 Westend Ave Suite 1D New York, NY 10023 Bill To: Bill For: Bill as of: Date Apr 10.2014 Transaction CPT Code Diagnosis Total Owed 4/912014 Clinical Intake/ Psychiatric Evalualit 90792 $3,500.00 4/912014 Payment -- (53.50B00) $0.00 Please Pay this Amount: $0.00 Charges for services to be rendered. please pay balance before neurological testing appointment. Tax ID Kamran Fallahpour, PhD License Number: 015910 Tax Id:M5 NPI: I EFTA00602690

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