Provider Demographics
NPI:1700439247
Name:DELLA VALLE, JENNIFER ANN (ATR-BC, LCAT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:DELLA VALLE
Suffix:
Gender:F
Credentials:ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-3118
Mailing Address - Country:US
Mailing Address - Phone:631-494-6389
Mailing Address - Fax:
Practice Address - Street 1:2 CORACI BLVD STE 10
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-4833
Practice Address - Country:US
Practice Address - Phone:631-494-6389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002151221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty