Provider Demographics
NPI:1154761260
Name:PERDOMO, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:PERDOMO
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 1:417 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4636
Mailing Address - Country:US
Mailing Address - Phone:631-926-1908
Mailing Address - Fax:
Practice Address - Street 1:417 S 6TH ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4636
Practice Address - Country:US
Practice Address - Phone:631-926-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY869150252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency