Provider Demographics
NPI:1336246032
Name:DERMAN, TONI B (LCSW)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:B
Last Name:DERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LANDING LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1106
Mailing Address - Country:US
Mailing Address - Phone:631-473-6994
Mailing Address - Fax:631-473-6994
Practice Address - Street 1:33 LANDING LN
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1106
Practice Address - Country:US
Practice Address - Phone:631-473-6994
Practice Address - Fax:631-473-6994
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR041649-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01502083Medicaid
NY01502083Medicaid