Provider Demographics
NPI:1740793116
Name:COLLETTI, ANTONIO V
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:V
Last Name:COLLETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7119 80TH ST STE 8210
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7733
Practice Address - Country:US
Practice Address - Phone:718-554-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist