Provider Demographics
NPI:1245582840
Name:PEZZULLO, MICHAEL (SLP CCC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PEZZULLO
Suffix:
Gender:M
Credentials:SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ENTRANCE WAY
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-1315
Mailing Address - Country:US
Mailing Address - Phone:845-628-6215
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC BAVARIA
Practice Address - Street 2:CMR 411, BLDG 700, ROSE BARRACKS
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:49966-283-4719
Practice Address - Fax:49966-283-4721
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020537235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN