Provider Demographics
NPI:1649963554
Name:VILLALTA, ELIZABETH (LAC-DIPL)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:LAC-DIPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2806
Mailing Address - Country:US
Mailing Address - Phone:516-509-5877
Mailing Address - Fax:
Practice Address - Street 1:26 MILLER CIR
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1805
Practice Address - Country:US
Practice Address - Phone:516-509-5877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6952171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist