Provider Demographics
NPI:1861769903
Name:STAVRIS-LATHAM, DEANNA (MSED)
Entity type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:
Last Name:STAVRIS-LATHAM
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 LAUREL HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-9636
Mailing Address - Country:US
Mailing Address - Phone:516-692-7985
Mailing Address - Fax:516-692-4845
Practice Address - Street 1:1597 LAUREL HOLLOW RD
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-9636
Practice Address - Country:US
Practice Address - Phone:516-692-7985
Practice Address - Fax:516-692-4845
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY19131711Medicaid