Provider Demographics
NPI:1023576097
Name:VIVINO, DEANNA (MED)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:
Last Name:VIVINO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MEADOWBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-3857
Mailing Address - Country:US
Mailing Address - Phone:732-546-4782
Mailing Address - Fax:
Practice Address - Street 1:2320 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4411
Practice Address - Country:US
Practice Address - Phone:609-503-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-18-33000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst