Provider Demographics
NPI:1376362590
Name:MAMARONECK NP IN PSYCHIATRY PLLC
Entity type:Organization
Organization Name:MAMARONECK NP IN PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JACQ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PMHNP-BC
Authorized Official - Phone:917-513-0273
Mailing Address - Street 1:709 PALMER CT APT 2E
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 PALMER CT APT 2E
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-2442
Practice Address - Country:US
Practice Address - Phone:917-513-0273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health