Provider Demographics
NPI:1972909117
Name:PSYLLOS, DESPINA
Entity Type:Individual
Prefix:MS
First Name:DESPINA
Middle Name:
Last Name:PSYLLOS
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 1:2334 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3415
Mailing Address - Country:US
Mailing Address - Phone:347-596-6700
Mailing Address - Fax:
Practice Address - Street 1:2125 76TH ST
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1202
Practice Address - Country:US
Practice Address - Phone:347-596-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health