Provider Demographics
NPI:1558838839
Name:MICCIULLI, CHRISTINA (MS)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:MICCIULLI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 JEFFERSONVILLE N BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:NY
Mailing Address - Zip Code:12766-5217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:12940-7656
Practice Address - Country:US
Practice Address - Phone:845-343-2499
Practice Address - Fax:845-394-0168
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP13367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health