Healthcare Provider Details

I. General information

NPI: 1003307216
Provider Name (Legal Business Name): ALEXA MARIE PANTANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 AVE AT PORT IMPERIAL APT 1042
WEST NEW YORK NJ
07093-7045
US

IV. Provider business mailing address

250 HARRISON AVE
MINEOLA NY
11501-3943
US

V. Phone/Fax

Practice location:
  • Phone: 973-865-9269
  • Fax:
Mailing address:
  • Phone: 973-865-9269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP05237
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: