Provider Demographics
NPI:1467646059
Name:NERESTAN, DOMINIQUE (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:
Last Name:NERESTAN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 BAINBRIDGE AVE
Mailing Address - Street 2:APT S1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-1419
Mailing Address - Country:US
Mailing Address - Phone:718-708-5655
Mailing Address - Fax:888-812-4062
Practice Address - Street 1:3510 BAINBRIDGE AVE
Practice Address - Street 2:APT S1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1419
Practice Address - Country:US
Practice Address - Phone:718-708-5655
Practice Address - Fax:888-812-4062
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR063179-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR063179OtherNYS LICENSE