Provider Demographics
NPI:1962829291
Name:SERVELLO, VICKI (SPECIAL EDUCATION)
Entity Type:Individual
Prefix:MISS
First Name:VICKI
Middle Name:
Last Name:SERVELLO
Suffix:
Gender:F
Credentials:SPECIAL EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 CANDLEWICK LN
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1044
Mailing Address - Country:US
Mailing Address - Phone:315-673-9037
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:315-437-4690
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY534966941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY534966941OtherSPECIAL EDUCATION TEACHER