Provider Demographics
NPI:1720389497
Name:ACQUAVIVA, TANYA (MS)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:ACQUAVIVA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 VIBURNUM LN
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-3927
Mailing Address - Country:US
Mailing Address - Phone:315-735-7709
Mailing Address - Fax:
Practice Address - Street 1:104 VIBURNUM LN
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-3927
Practice Address - Country:US
Practice Address - Phone:315-735-7709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005805-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist