Provider Demographics
NPI:1346543360
Name:DESANTIS, DOMENIC (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:CROTON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:10519-0873
Mailing Address - Country:US
Mailing Address - Phone:914-329-5106
Mailing Address - Fax:
Practice Address - Street 1:1283 ROUTE 311
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:NY
Practice Address - Zip Code:12563-2832
Practice Address - Country:US
Practice Address - Phone:914-329-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012473-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist