Provider Demographics
NPI:1295097145
Name:TYAGI, VIBHA (MS IN EDU&SP EDU)
Entity type:Individual
Prefix:MS
First Name:VIBHA
Middle Name:
Last Name:TYAGI
Suffix:
Gender:F
Credentials:MS IN EDU&SP EDU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2211
Mailing Address - Country:US
Mailing Address - Phone:631-667-0235
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD
Practice Address - Street 2:SUITE #202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3676
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16330171M00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator