Provider Demographics
NPI:1336216068
Name:MITTMAN, ROBERTA R (LAC)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:R
Last Name:MITTMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E 40TH ST
Mailing Address - Street 2:201
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0401
Mailing Address - Country:US
Mailing Address - Phone:212-686-0939
Mailing Address - Fax:
Practice Address - Street 1:15 E 40TH ST
Practice Address - Street 2:201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0401
Practice Address - Country:US
Practice Address - Phone:212-686-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001037171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist