Provider Demographics
NPI:1700410339
Name:KOSTOUROS-GAITANERIS, DIMITRA (PMHC)
Entity Type:Individual
Prefix:
First Name:DIMITRA
Middle Name:
Last Name:KOSTOUROS-GAITANERIS
Suffix:
Gender:F
Credentials:PMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:THE FORTUNE SOCIETY INC.
Practice Address - Street 2:29-76 NORTHERN BLVD 2ND FL
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2822
Practice Address - Country:US
Practice Address - Phone:212-691-7554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-22
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP104909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health