Provider Demographics
NPI:1083481113
Name:PERSAUD, AMANDA DIANA (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANA
Last Name:PERSAUD
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 1:4628 VERNON BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5352
Mailing Address - Country:US
Mailing Address - Phone:646-902-4792
Mailing Address - Fax:
Practice Address - Street 1:475 48TH AVE APT 3413
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11109-5527
Practice Address - Country:US
Practice Address - Phone:646-902-4792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical