Provider Demographics
NPI:1770507014
Name:DECROSTA, RICHARD L
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:DECROSTA
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 1:909 STATE ROUTE 299
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-5022
Mailing Address - Country:US
Mailing Address - Phone:845-338-1234
Mailing Address - Fax:
Practice Address - Street 1:139 CORNELL ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3633
Practice Address - Country:US
Practice Address - Phone:845-338-1234
Practice Address - Fax:845-338-6284
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001215OtherLICENSE