1104047620 NPI number — JOANNE MARIE RESTIVO M.S., CCC

Table of content: JOANNE MARIE RESTIVO M.S., CCC (NPI 1104047620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104047620 NPI number — JOANNE MARIE RESTIVO M.S., CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RESTIVO
Provider First Name:
JOANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104047620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3959 BROADWAY
Provider Second Line Business Mailing Address:
ROOM 501N
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10032-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-305-8933
Provider Business Mailing Address Fax Number:
212-305-6142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3959 BROADWAY
Provider Second Line Business Practice Location Address:
ROOM 501N
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032-1559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-305-8933
Provider Business Practice Location Address Fax Number:
212-305-6142
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  002145-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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