Healthcare Provider Details

I. General information

NPI: 1487214680
Provider Name (Legal Business Name): DINA DERILAS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6729 MYRTLE AVE
GLENDALE NY
11385-7063
US

IV. Provider business mailing address

6729 MYRTLE AVE
GLENDALE NY
11385-7063
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7001
  • Fax: 718-456-9470
Mailing address:
  • Phone: 718-456-7001
  • Fax: 718-456-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number014166
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: