Healthcare Provider Details

I. General information

NPI: 1750553335
Provider Name (Legal Business Name): MARNELLE DERONETTE MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 WESTCHESTER AVE
BRONX NY
10462-4504
US

IV. Provider business mailing address

279 MAIN ST SUITE 204
NEW PALTZ NY
12561-1623
US

V. Phone/Fax

Practice location:
  • Phone: 718-239-1610
  • Fax: 718-792-7053
Mailing address:
  • Phone: 845-255-3046
  • Fax: 845-255-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004101-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: