Provider Demographics
NPI:1144788829
Name:ALBA, DENISE MARIE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:ALBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4230
Mailing Address - Country:US
Mailing Address - Phone:516-935-6858
Mailing Address - Fax:
Practice Address - Street 1:180 BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4230
Practice Address - Country:US
Practice Address - Phone:516-935-6858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113422018Medicaid