Basic Information
| Provider Information | |||||||||
| NPI: | 1790360824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEMISTOCLEOUS | ||||||||
| FirstName: | MARINA | ||||||||
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| Credential: | MHC-LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6001 171ST ST | ||||||||
| Address2: | |||||||||
| City: | FRESH MEADOWS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113651509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179157319 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 UNION SQ W FL 7 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126279600 | ||||||||
| FaxNumber: | 2126274040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2021 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.