Provider Demographics
NPI:1942224266
Name:DESANTIS, SANDRA (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2648
Mailing Address - Country:US
Mailing Address - Phone:516-410-6849
Mailing Address - Fax:
Practice Address - Street 1:910 W END AVE
Practice Address - Street 2:1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3533
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-932-0964
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01928578Medicaid
NY01928578Medicaid
NYA400050499Medicare PIN