Healthcare Provider Details

I. General information

NPI: 1265923346
Provider Name (Legal Business Name): DANA VICKERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

13030 180TH ST
JAMAICA NY
11434-4108
US

IV. Provider business mailing address

22004 138TH AVE
LAURELTON NY
11413-2325
US

V. Phone/Fax

Practice location:
  • Phone: 718-527-2200
  • Fax:
Mailing address:
  • Phone: 516-647-3053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number18-068
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: