Provider Demographics
NPI:1649898453
Name:VICENCIO, ANNALISSA G (MA, LCAT, MT-BC)
Entity type:Individual
Prefix:
First Name:ANNALISSA
Middle Name:G
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:MA, LCAT, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W 15TH ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6414
Mailing Address - Country:US
Mailing Address - Phone:914-481-2283
Mailing Address - Fax:888-651-4682
Practice Address - Street 1:205 W 15TH ST APT 2E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6414
Practice Address - Country:US
Practice Address - Phone:914-481-2283
Practice Address - Fax:888-651-4682
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12125225A00000X
NY002111225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist