Provider Demographics
NPI:1194883884
Name:DESANTIS, THERESA IRENE (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:IRENE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:32 SALLY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1434
Mailing Address - Country:US
Mailing Address - Phone:516-637-0689
Mailing Address - Fax:631-414-7178
Practice Address - Street 1:1111 BROADHOLLOW RD
Practice Address - Street 2:SUITE 204
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4820
Practice Address - Country:US
Practice Address - Phone:631-414-7181
Practice Address - Fax:631-414-7178
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical