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General NPI Number Information
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NPI Number | 1548555071
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Entity Type | Individual
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Provider Name | DIANNE H. DISSTON LP
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Gender | Male
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Dates
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Enumeration Date | 06/13/2011
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Last Update Date | 06/13/2011
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Provider Practice Location Address
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Address Line | 967 ROUTE 22
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City | BREWSTER
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State | NY
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Zip | 10509-1526
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Country | US
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Telephone | 845-494-6789
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Fax |
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Provider Business Mailing Address
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Address Line | 16 LACONA DR
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City | PATTERSON
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State | NY
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Zip | 12563-2023
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Country | US
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Telephone | 845-494-6789
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 102L00000X
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Taxonomy Name | Psychoanalyst
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License Number | 19 000868
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License Number State | NY
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