Provider Demographics
NPI:1922855105
Name:VULTAGGIO, CERISSA (LMHC)
Entity type:Individual
Prefix:
First Name:CERISSA
Middle Name:
Last Name:VULTAGGIO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-3819
Mailing Address - Country:US
Mailing Address - Phone:347-535-2504
Mailing Address - Fax:
Practice Address - Street 1:8 W 8TH ST
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3819
Practice Address - Country:US
Practice Address - Phone:347-535-2504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health