Basic Information
| Provider Information | |||||||||
| NPI: | 1033277496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIBENEDETTO | ||||||||
| FirstName: | ENZA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S.M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3334 209TH ST | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113611462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183525271 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104-70 QUEENS BOULEVARD SUITE 200 | ||||||||
| Address2: | BLEULER PSYCHOTHERAPY CENTER | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182756010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 001504 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.