Healthcare Provider Details

I. General information

NPI: 1316076854
Provider Name (Legal Business Name): RENEE E VACCARO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NORTHERN BLVD STE 11
GREAT NECK NY
11021-4802
US

IV. Provider business mailing address

475 NORTHERN BLVD STE 11
GREAT NECK NY
11021-4802
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-0030
  • Fax: 516-466-7723
Mailing address:
  • Phone: 516-829-0030
  • Fax: 516-466-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number028966
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: