Provider Demographics
NPI:1447742044
Name:PETSAGOURAKIS, DESPINA (MA)
Entity Type:Individual
Prefix:
First Name:DESPINA
Middle Name:
Last Name:PETSAGOURAKIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5802
Mailing Address - Country:US
Mailing Address - Phone:646-754-5000
Mailing Address - Fax:
Practice Address - Street 1:1 PARK AVE FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5818
Practice Address - Country:US
Practice Address - Phone:646-754-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
MA390200000X
NY025838103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program