Provider Demographics
NPI:1154678555
Name:DELLAVALLE, ANNEMARIE
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:
Last Name:DELLAVALLE
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 1:1087 RENSSELAER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1087 RENSSELAER AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2116
Practice Address - Country:US
Practice Address - Phone:917-439-2985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY719140174400000X
NJTL-2367235Z00000X
NY024752235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist