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Organization
PROFESSIONAL PRACTICE GROUP, DEPT. OF PSYCH
Active
Organization
PROFESSIONAL PRACTICE GROUP, DEPT. OF PSYCH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MANTOSH J DEWAN M.D. (PRESIDENT)
(315) 464-3119
Entity
Organization
Contact information
Practice address
750 E ADAMS ST, SYRACUSE, NY 13210-2306
(315) 464-3119
(315) 464-3282
Mailing address
750 E ADAMS ST, SYRACUSE, NY 13210-2306
(315) 464-3119
(315) 464-3282
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00570654
—
NY
Enumeration date
06/12/2006
Last updated
09/11/2025
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