Healthcare Provider Details

I. General information

NPI: 1003721788
Provider Name (Legal Business Name): VIJAY RAMANATHAN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: VEGAS K JARROW LAC

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10302 ROCKAWAY BEACH BLVD # 1A
ROCKAWAY PARK NY
11694-2796
US

IV. Provider business mailing address

10302 ROCKAWAY BEACH BLVD # 1A
ROCKAWAY PARK NY
11694-2796
US

V. Phone/Fax

Practice location:
  • Phone: 646-769-0857
  • Fax:
Mailing address:
  • Phone: 646-769-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00828700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: