Healthcare Provider Details

I. General information

NPI: 1356995302
Provider Name (Legal Business Name): ROMONA YIZAR LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FORTUNE RD W
MIDDLETOWN NY
10941-1625
US

IV. Provider business mailing address

15 FORTUNE RD W
MIDDLETOWN NY
10941-1625
US

V. Phone/Fax

Practice location:
  • Phone: 845-240-7707
  • Fax:
Mailing address:
  • Phone: 845-240-7707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number009699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: