Provider Demographics
NPI:1740772029
Name:CRIVELLI, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CRIVELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 INDIAN HEAD RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4401
Mailing Address - Country:US
Mailing Address - Phone:631-387-2627
Mailing Address - Fax:
Practice Address - Street 1:87 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4401
Practice Address - Country:US
Practice Address - Phone:631-387-2627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialist