Provider Demographics
NPI:1154471233
Name:DESIDERIO, JILLIAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:
Last Name:DESIDERIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MAPLE HILL ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4176
Mailing Address - Country:US
Mailing Address - Phone:914-962-5593
Mailing Address - Fax:914-962-5599
Practice Address - Street 1:2000 MAPLE HILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4176
Practice Address - Country:US
Practice Address - Phone:914-962-5593
Practice Address - Fax:914-962-5599
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069449-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY250248OtherHEALTHNET
NYNY6001Medicare ID - Type Unspecified