Provider Demographics
NPI:1740595743
Name:DETURA, DONNA (RLCSW, CASAC)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:DETURA
Suffix:
Gender:F
Credentials:RLCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-0335
Mailing Address - Country:US
Mailing Address - Phone:631-379-3436
Mailing Address - Fax:631-345-3591
Practice Address - Street 1:701 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8894
Practice Address - Country:US
Practice Address - Phone:631-379-3436
Practice Address - Fax:631-345-3591
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR051498-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4154436Medicaid
NYA300133378OtherMEDICARE