Provider Demographics
NPI:1619408747
Name:DESMOND, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:DESMOND
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 1:265 EDGEWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-2103
Mailing Address - Country:US
Mailing Address - Phone:631-885-0951
Mailing Address - Fax:
Practice Address - Street 1:333 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1231
Practice Address - Country:US
Practice Address - Phone:516-634-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2909101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2909OtherCASAC CERTIFICATE