Provider Demographics
NPI:1972867174
Name:DUARTE, LIDIA GRACIELA (MA)
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:GRACIELA
Last Name:DUARTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LIDIA
Other - Middle Name:GRACIELA
Other - Last Name:CORVALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:918 127TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-1928
Mailing Address - Country:US
Mailing Address - Phone:917-318-7545
Mailing Address - Fax:
Practice Address - Street 1:918 127TH ST
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-1928
Practice Address - Country:US
Practice Address - Phone:917-318-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1179623103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool