Provider Demographics
NPI:1124638093
Name:DE LA TORRE, EXON
Entity type:Individual
Prefix:
First Name:EXON
Middle Name:
Last Name:DE LA TORRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1042
Mailing Address - Country:US
Mailing Address - Phone:347-658-9244
Mailing Address - Fax:
Practice Address - Street 1:1705 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-1057
Practice Address - Country:US
Practice Address - Phone:347-658-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker