Provider Demographics
NPI:1366941288
Name:TRIVISONNO, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:TRIVISONNO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 W 64TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6727
Mailing Address - Country:US
Mailing Address - Phone:617-834-9348
Mailing Address - Fax:
Practice Address - Street 1:1990 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4553
Practice Address - Country:US
Practice Address - Phone:718-828-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0759541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical