Provider Demographics
NPI:1831651421
Name:ZYDOR, DOREEN J (NYS CASAC- T, NYCPS)
Entity Type:Individual
Prefix:MISS
First Name:DOREEN
Middle Name:J
Last Name:ZYDOR
Suffix:
Gender:F
Credentials:NYS CASAC- T, NYCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:CALLICOON
Mailing Address - State:NY
Mailing Address - Zip Code:12723-5414
Mailing Address - Country:US
Mailing Address - Phone:845-791-0170
Mailing Address - Fax:
Practice Address - Street 1:28 HORSESHOE LN
Practice Address - Street 2:
Practice Address - City:CALLICOON
Practice Address - State:NY
Practice Address - Zip Code:12723-5414
Practice Address - Country:US
Practice Address - Phone:845-791-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33852101YA0400X
NYNYCPS-P-1777175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33852OtherNYS OASAS
NYDY28409ZMedicaid
NYNYCPS-P-1777OtherNY PEER SPECIALIST