=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558695825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MARIA DIMITRI PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2009
-----------------------------------------------------
Last Update Date | 09/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 3RD AVE SUITE 505
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-495-3078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2240 35TH ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-642-3201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 017620
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------