Provider Demographics
NPI:1225177801
Name:VALENCIA, VIVENCIO S (PT)
Entity Type:Individual
Prefix:
First Name:VIVENCIO
Middle Name:S
Last Name:VALENCIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S WASHINGTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2919
Mailing Address - Country:US
Mailing Address - Phone:201-244-8908
Mailing Address - Fax:201-244-8907
Practice Address - Street 1:223 S WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2919
Practice Address - Country:US
Practice Address - Phone:201-244-8908
Practice Address - Fax:201-244-8907
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01130200225100000X
NY026260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist