Provider Demographics
NPI:1356306880
Name:VIGLIOTTA, PETER (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:VIGLIOTTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2125
Mailing Address - Country:US
Mailing Address - Phone:631-580-9364
Mailing Address - Fax:631-580-9365
Practice Address - Street 1:1855 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7949
Practice Address - Country:US
Practice Address - Phone:631-580-9364
Practice Address - Fax:631-580-9365
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040667-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02247547Medicaid
NYR49105Medicare UPIN
NYPV0N795230Medicare ID - Type Unspecified