Provider Demographics
NPI:1841360112
Name:LATENDRESSE, DANIEL JOHN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:LATENDRESSE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 SAINT MARKS PL
Mailing Address - Street 2:APT 408
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1859
Mailing Address - Country:US
Mailing Address - Phone:718-744-4753
Mailing Address - Fax:
Practice Address - Street 1:1657 BEDFORD AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-2009
Practice Address - Country:US
Practice Address - Phone:718-363-3261
Practice Address - Fax:718-363-5074
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02607927Medicaid
NY02607927Medicaid