Healthcare Provider Details

I. General information

NPI: 1790440584
Provider Name (Legal Business Name): PETER FRANK FATA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 OLD NYACK TPKE
SPRING VALLEY NY
10977-5842
US

IV. Provider business mailing address

314 OLD NYACK TPKE
SPRING VALLEY NY
10977-5842
US

V. Phone/Fax

Practice location:
  • Phone: 845-548-6617
  • Fax:
Mailing address:
  • Phone: 845-548-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082997
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: