Provider Demographics
NPI:1093395105
Name:YPHANTIDES, DIANNA NICOLE (LSW)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:NICOLE
Last Name:YPHANTIDES
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35-06 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5219
Mailing Address - Country:US
Mailing Address - Phone:201-663-0419
Mailing Address - Fax:
Practice Address - Street 1:4 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-5237
Practice Address - Country:US
Practice Address - Phone:973-922-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06487900101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty