Provider Demographics
NPI:1467504951
Name:PROVINO, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:PROVINO
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 1:1156 N BROADWAY
Mailing Address - Street 2:ANDRUS CHILDREN'S CENTER
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1108
Mailing Address - Country:US
Mailing Address - Phone:914-965-3700
Mailing Address - Fax:914-965-3883
Practice Address - Street 1:30 S BROADWAY
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-3712
Practice Address - Country:US
Practice Address - Phone:914-968-1663
Practice Address - Fax:914-968-1664
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY0802051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCY NPI #
NY00355940OtherAGENCY MEDICAID #
NYWVE061Medicare ID - Type UnspecifiedAGENCY MEDICARE PROVIDER#