Provider Demographics
NPI:1255186680
Name:VECCHIO, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VECCHIO
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 1:224 FAIR ST STE 9
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4561
Mailing Address - Country:US
Mailing Address - Phone:413-203-4567
Mailing Address - Fax:
Practice Address - Street 1:224 FAIR ST STE 9
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4561
Practice Address - Country:US
Practice Address - Phone:413-203-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001205102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty