Provider Demographics
NPI:1639735012
Name:YESIN, DMITRIY
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:YESIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 E 12TH ST APT 416
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4616
Mailing Address - Country:US
Mailing Address - Phone:347-851-0361
Mailing Address - Fax:
Practice Address - Street 1:465 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4800
Practice Address - Country:US
Practice Address - Phone:212-420-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-12
Last Update Date:2019-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY910944103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY800693122Medicaid