Provider Demographics
NPI:1194126490
Name:LAVACCA, ADRIENNE MARIE (ATC)
Entity type:Individual
Prefix:MS
First Name:ADRIENNE
Middle Name:MARIE
Last Name:LAVACCA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 ROANOKE ST
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3055
Mailing Address - Country:US
Mailing Address - Phone:516-679-5096
Mailing Address - Fax:
Practice Address - Street 1:3657 ROANOKE ST
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-3055
Practice Address - Country:US
Practice Address - Phone:516-679-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000590-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer