Healthcare Provider Details

I. General information

NPI: 1801265491
Provider Name (Legal Business Name): ATHENA VACCARO M.S., P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 CARPENTER AVE
SEA CLIFF NY
11579-2102
US

IV. Provider business mailing address

431 CARPENTER AVE
SEA CLIFF NY
11579-2102
US

V. Phone/Fax

Practice location:
  • Phone: 646-872-3287
  • Fax:
Mailing address:
  • Phone: 646-872-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number012818-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: