Healthcare Provider Details

I. General information

NPI: 1750102737
Provider Name (Legal Business Name): CHRISTINA ELIZABETH CIVITELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14379 ROUTE 9W
RAVENA NY
12143
US

IV. Provider business mailing address

498 GREEN LAKE RD
CATSKILL NY
12414-6213
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-3124
  • Fax:
Mailing address:
  • Phone: 518-943-9697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: