Healthcare Provider Details

I. General information

NPI: 1912345489
Provider Name (Legal Business Name): LEYLA I DITTERLIZZI MS CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 PEMART AVE N/A
PEEKSKILL NY
10566-2213
US

IV. Provider business mailing address

965 PEMART AVE N/A
PEEKSKILL NY
10566-2213
US

V. Phone/Fax

Practice location:
  • Phone: 914-329-1213
  • Fax:
Mailing address:
  • Phone: 914-329-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17228
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: