Provider Demographics
NPI:1760255764
Name:DEMETRIUS, MAURINE CELINA (LP)
Entity Type:Individual
Prefix:
First Name:MAURINE
Middle Name:CELINA
Last Name:DEMETRIUS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13921 85TH DR
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2730
Mailing Address - Country:US
Mailing Address - Phone:347-537-9427
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST STE 502
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:718-426-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06-P125607-01106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist