Provider Demographics
NPI:1154754935
Name:PRENDERGAST, JOANNE
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:PRENDERGAST
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 1:2 SQUIRREL DR
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-2217
Mailing Address - Country:US
Mailing Address - Phone:516-987-2716
Mailing Address - Fax:
Practice Address - Street 1:992 GATES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3602
Practice Address - Country:US
Practice Address - Phone:718-483-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1370661103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool