| Doctor Name: | MARISSA A. TANTILLO LICATA |
| NPI Number: | 1134180169 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | RD |
| License Number: | 877337 |
| Business Practice Address: | 177 Fort Washington Ave Vc- 4th Floor Area 1, Room H New York, NY - 100323733 |
| Business Phone Number: | 2123057151 |
| Business Fax Number: | |
| Mailing Address: | 14 Bernard St, LAWRENCE |
| State: | NY |
| Postal Code: | 115591245 |
| Phone Number: | 5162391441 |
| Fax Number: | |
| NPI Enumeration Date: | 03/29/2006 |
| NPI Last Update Date: | 09/13/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 133V00000X |
| License Number: | 877337 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Dietary & Nutritional Service Providers |
| Taxonomy Classification: | Dietitian, Registered |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A registered dietician (RD) is a food and nutrition expert who has successfully completed a minimum of a bachelor |