Basic Information
| Provider Information | |||||||||
| NPI: | 1316134430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JESURASA | ||||||||
| FirstName: | SUBASHINI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 WHEATLEY RD | ||||||||
| Address2: | |||||||||
| City: | GLEN HEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115452641 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 189 WHEATLEY RD | ||||||||
| Address2: | |||||||||
| City: | GLEN HEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115452641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166261000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
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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 | 103TS0200X | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.