Provider Demographics
NPI:1124559281
Name:WINSTON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WINSTON
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 1:11518 175TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1850
Mailing Address - Country:US
Mailing Address - Phone:347-526-1991
Mailing Address - Fax:
Practice Address - Street 1:11518 175TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1850
Practice Address - Country:US
Practice Address - Phone:347-526-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10671OtherNYS EARLY INTERVENTION PROGRAM