Provider Demographics
NPI:1366755712
Name:VACCARELLA, TINA MARIE (OTR)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:VACCARELLA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-1296
Mailing Address - Country:US
Mailing Address - Phone:631-355-9066
Mailing Address - Fax:
Practice Address - Street 1:1800 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:CUTCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11935-1296
Practice Address - Country:US
Practice Address - Phone:631-355-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0107881225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics