Provider Demographics
NPI:1114296829
Name:ANTHONY, MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 FULTON AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3634
Practice Address - Country:US
Practice Address - Phone:516-408-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1087242101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1087242Medicare PIN