Provider Demographics
NPI:1578826202
Name:DESIMONE, MARILYN
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:
Last Name:DESIMONE
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 1:71 OLD TOWN LN
Mailing Address - Street 2:
Mailing Address - City:HALESITE
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2219
Mailing Address - Country:US
Mailing Address - Phone:516-297-0598
Mailing Address - Fax:
Practice Address - Street 1:71 OLD TOWN LN
Practice Address - Street 2:
Practice Address - City:HALESITE
Practice Address - State:NY
Practice Address - Zip Code:11743-2219
Practice Address - Country:US
Practice Address - Phone:516-297-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-10-7600103K00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist