Provider Demographics
NPI:1457115040
Name:DIMARIA, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:DIMARIA
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 1:5 DOBEK TER
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2034
Mailing Address - Country:US
Mailing Address - Phone:194-984-2747
Mailing Address - Fax:
Practice Address - Street 1:177 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5203
Practice Address - Country:US
Practice Address - Phone:203-559-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1528101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)