Healthcare Provider Details

I. General information

NPI: 1487630877
Provider Name (Legal Business Name): JOHN P VICEDOMINI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN P VICEDOMINI PHD PLLC

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1286 SHAW PL
SEAFORD NY
11783-1747
US

IV. Provider business mailing address

1286 SHAW PL
SEAFORD NY
11783-1747
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-2032
  • Fax:
Mailing address:
  • Phone: 516-221-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0129651
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: