Provider Demographics
NPI:1053641548
Name:VINSON, TERAESA (PHD)
Entity Type:Individual
Prefix:
First Name:TERAESA
Middle Name:
Last Name:VINSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 33RD ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2422
Mailing Address - Country:US
Mailing Address - Phone:917-309-4636
Mailing Address - Fax:
Practice Address - Street 1:330 W 58TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1827
Practice Address - Country:US
Practice Address - Phone:917-309-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist