Provider Demographics
NPI:1275998635
Name:MITRAKOS, TIFFANY (MSED)
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:
Last Name:MITRAKOS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 KENT ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2317
Mailing Address - Country:US
Mailing Address - Phone:315-797-2233
Mailing Address - Fax:315-272-1914
Practice Address - Street 1:507 KENT ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2317
Practice Address - Country:US
Practice Address - Phone:315-797-2233
Practice Address - Fax:315-272-1914
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY974527151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist