Provider Demographics
NPI:1790440584
Name:FATA, PETER FRANK
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:FRANK
Last Name:FATA
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 1:314 OLD NYACK TPKE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-5842
Mailing Address - Country:US
Mailing Address - Phone:845-548-6617
Mailing Address - Fax:
Practice Address - Street 1:314 OLD NYACK TPKE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5842
Practice Address - Country:US
Practice Address - Phone:845-548-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0829971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty