Provider Demographics
NPI:1104336379
Name:DOMJAN, ESZTER
Entity type:Individual
Prefix:
First Name:ESZTER
Middle Name:
Last Name:DOMJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 W 147TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4803
Mailing Address - Country:US
Mailing Address - Phone:646-532-7877
Mailing Address - Fax:
Practice Address - Street 1:110 W 96TH ST APT 1D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6412
Practice Address - Country:US
Practice Address - Phone:646-663-5973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007925-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health