Provider Demographics
NPI:1265677090
Name:MIELNICK, MATTHEW (OTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MIELNICK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2063 RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:CLAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13322-1005
Mailing Address - Country:US
Mailing Address - Phone:315-839-6007
Mailing Address - Fax:315-853-2076
Practice Address - Street 1:2063 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:CLAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:13322-1005
Practice Address - Country:US
Practice Address - Phone:315-839-6007
Practice Address - Fax:315-853-2076
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009440-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist