Provider Demographics
NPI:1629801535
Name:ILDEFONSO-PATINO, YANIRA CORALYN (MHC-LP)
Entity type:Individual
Prefix:
First Name:YANIRA
Middle Name:CORALYN
Last Name:ILDEFONSO-PATINO
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 JERUSALEM AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-2957
Mailing Address - Country:US
Mailing Address - Phone:516-425-4062
Mailing Address - Fax:
Practice Address - Street 1:350 JERICHO TPKE STE 103
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1317
Practice Address - Country:US
Practice Address - Phone:516-425-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP128403101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty