Provider Demographics
NPI:1235445370
Name:VACIRCA, MARY JANE (MS, PT)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:VACIRCA
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1621
Mailing Address - Country:US
Mailing Address - Phone:631-748-9519
Mailing Address - Fax:
Practice Address - Street 1:123 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1621
Practice Address - Country:US
Practice Address - Phone:631-748-9519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist