Healthcare Provider Details

I. General information

NPI: 1982287025
Provider Name (Legal Business Name): WINSOME DIANA MCDERMOTT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD STE 1C
REGO PARK NY
11374-4414
US

IV. Provider business mailing address

535 CUTWATER TRL
SANDY SPRINGS GA
30328-1817
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax:
Mailing address:
  • Phone: 929-302-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number101709-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: