Provider Demographics
NPI:1063545911
Name:FORTINO, DENISE (PHD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:FORTINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SECOND AVENUE
Mailing Address - Street 2:12TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-360-7781
Mailing Address - Fax:212-360-7487
Practice Address - Street 1:1900 SECOND AVENUE
Practice Address - Street 2:12TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-360-7781
Practice Address - Fax:212-360-7487
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015736103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist