Provider Demographics
NPI:1194135467
Name:VIVACQUA, CAROLINE KAY
Entity type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:KAY
Last Name:VIVACQUA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CAROLINE
Other - Middle Name:KAY
Other - Last Name:PINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 TARRY LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4026
Mailing Address - Country:US
Mailing Address - Phone:646-284-2602
Mailing Address - Fax:
Practice Address - Street 1:2550 88TH ST
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-1010
Practice Address - Country:US
Practice Address - Phone:718-397-7851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025013235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04307851Medicaid