Provider Demographics
NPI:1205938792
Name:VIGLIETTA, MARTHA B (PHD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:B
Last Name:VIGLIETTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E GENESEE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3130
Mailing Address - Country:US
Mailing Address - Phone:315-476-2675
Mailing Address - Fax:315-476-2678
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-476-2675
Practice Address - Fax:315-476-2678
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008485103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01159388Medicaid
NY01159388Medicaid