Provider Demographics
NPI:1417671306
Name:DICK, KETRINA GABRIELLE
Entity Type:Individual
Prefix:
First Name:KETRINA
Middle Name:GABRIELLE
Last Name:DICK
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 1:100 BENCHLEY PL APT 9B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-3344
Mailing Address - Country:US
Mailing Address - Phone:201-724-3369
Mailing Address - Fax:
Practice Address - Street 1:120 BENCHLEY PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-3402
Practice Address - Country:US
Practice Address - Phone:347-843-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist