Provider Demographics
NPI:1639762867
Name:SANGEMINO, JOHANNA LYN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:LYN
Last Name:SANGEMINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JOHANNA
Other - Middle Name:LYN
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:380 E SUNRISE HWY # 1028
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1906
Mailing Address - Country:US
Mailing Address - Phone:631-517-3251
Mailing Address - Fax:
Practice Address - Street 1:101 6TH AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1905
Practice Address - Country:US
Practice Address - Phone:917-580-7395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical