Provider Demographics
NPI:1821673971
Name:DOMENECH-RISTORUCCI, DEBRA DIANNE
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:DIANNE
Last Name:DOMENECH-RISTORUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 21ST RD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3940
Mailing Address - Country:US
Mailing Address - Phone:917-698-2902
Mailing Address - Fax:
Practice Address - Street 1:1842 21ST RD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3940
Practice Address - Country:US
Practice Address - Phone:917-698-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010007OtherPSYCHOLOGIST LICENSE
NY010007OtherPSYCHOLOGIST LICENSE