Provider Demographics
NPI:1063035590
Name:TAVOLACCI, ANNCHARLOTTE (LCAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:ANNCHARLOTTE
Middle Name:
Last Name:TAVOLACCI
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HAWKINS RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2035
Mailing Address - Country:US
Mailing Address - Phone:631-681-0310
Mailing Address - Fax:
Practice Address - Street 1:5225 RTE 347 STE 44
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-403-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001864221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist