Provider Demographics
NPI:1790954790
Name:IMMORDINO, ROSARY (LP)
Entity Type:Individual
Prefix:
First Name:ROSARY
Middle Name:
Last Name:IMMORDINO
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 1:8702 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-1431
Mailing Address - Country:US
Mailing Address - Phone:718-507-6843
Mailing Address - Fax:718-478-9128
Practice Address - Street 1:3242 91ST ST
Practice Address - Street 2:#304
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-2363
Practice Address - Country:US
Practice Address - Phone:718-651-8117
Practice Address - Fax:718-478-9128
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000025102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst