Provider Demographics
NPI:1962508465
Name:DIMETROSKY, RAYMOND S (DED)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:S
Last Name:DIMETROSKY
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SILVERLEAF CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457-1041
Mailing Address - Country:US
Mailing Address - Phone:201-666-2949
Mailing Address - Fax:
Practice Address - Street 1:4 SILVERLEAF CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457-1041
Practice Address - Country:US
Practice Address - Phone:201-666-2949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2159103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2159OtherNJ LICENSE NUMBER