1215390240 NPI number — MRS. JESSICA COHEN MICCIULLI L.M.H.C.

Table of content: MRS. JESSICA COHEN MICCIULLI L.M.H.C. (NPI 1215390240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215390240 NPI number — MRS. JESSICA COHEN MICCIULLI L.M.H.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICCIULLI
Provider First Name:
JESSICA
Provider Middle Name:
COHEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.M.H.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OCHERET
Provider Other First Name:
JESSICA
Provider Other Middle Name:
COHEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.M.H.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215390240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 STEWART AVE.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BETHPAGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-465-3998
Provider Business Mailing Address Fax Number:
212-531-3431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 STEWART AVE.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BETHPAGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-465-3998
Provider Business Practice Location Address Fax Number:
212-531-3431
Provider Enumeration Date:
03/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  006998-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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