Provider Demographics
NPI:1558416768
Name:SELVAGGIO, ANGELA MARIE (BAED)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:SELVAGGIO
Suffix:
Gender:F
Credentials:BAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 BAYPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1419
Mailing Address - Country:US
Mailing Address - Phone:631-868-3040
Mailing Address - Fax:
Practice Address - Street 1:539 BAYPORT AVE
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1419
Practice Address - Country:US
Practice Address - Phone:631-868-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1789450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist