=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962420737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LOUIS VILLANELLA PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W MAIN ST SUITE 208
-----------------------------------------------------
City | BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11702-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-482-1200
-----------------------------------------------------
Fax | 631-482-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 W MAIN ST SUITE 208
-----------------------------------------------------
City | BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11702-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-482-1200
-----------------------------------------------------
Fax | 631-482-1203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 014582
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------