MEDICARE: MRS. DEANNA VIVINO M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-18-33000	NJ

General Provider Information

NPI Number	:	1023576097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEANNA VIVINO M.ED.

Provider Business Mailing Address
First Line	:	50 MEADOWBROOK AVE
Second Line	:
City	:	LAWRENCEVILLE
State	:	NJ
Zip	:	08648-3857
Country	:	US
Telephone Number	:	732-546-4782
Fax Number	:

Provider Business Practice Location Address
First Line	:	2320 US HIGHWAY 1
Second Line	:
City	:	LAWRENCEVILLE
State	:	NJ
Zip	:	08648-4411
Country	:	US
Telephone Number	:	609-503-2544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2019
Last Update Date	:	03/07/2019

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