=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902430200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FONTANETTA NEUROPSYCHOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2020
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 NEW YORK AVE STE 230
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-505-3671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 NEW YORK AVE STE 230
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL NEUROPSYCHOLOGIST
-----------------------------------------------------
Name | DR. REBECCA A FONTANETTA
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 631-766-7969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------