Provider Demographics
NPI:1790997211
Name:MIRABITO, VANESSA ROSE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ROSE
Last Name:MIRABITO
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 1:220 S GENEVA ST
Mailing Address - Street 2:APT 4
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5425
Mailing Address - Country:US
Mailing Address - Phone:607-226-0142
Mailing Address - Fax:
Practice Address - Street 1:220 STEUBEN ST
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865-9740
Practice Address - Country:US
Practice Address - Phone:607-535-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0003562255A2300X
NY032370225100000X
NY001867-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer