Provider Demographics
NPI:1083185912
Name:IX-D'AMATO, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:IX-D'AMATO
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 1:390 CRYSTAL RUN RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4051
Mailing Address - Country:US
Mailing Address - Phone:845-673-4260
Mailing Address - Fax:
Practice Address - Street 1:390 CRYSTAL RUN RD STE 107
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4051
Practice Address - Country:US
Practice Address - Phone:845-673-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health