Provider Demographics
NPI:1467156679
Name:CERUTI, THERESA (MS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CERUTI
Suffix:
Gender:F
Credentials:MS
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 446
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11941-0446
Mailing Address - Country:US
Mailing Address - Phone:631-721-3922
Mailing Address - Fax:
Practice Address - Street 1:41 RIVER AVE
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:NY
Practice Address - Zip Code:11941-1216
Practice Address - Country:US
Practice Address - Phone:631-721-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool