Provider Demographics
NPI:1578084414
Name:ERCOLINO, BARBARA JEAN
Entity Type:Individual
Prefix:
First Name:BARBARA JEAN
Middle Name:
Last Name:ERCOLINO
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 1:56 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD S
Practice Address - Street 2:STONY BROOK UNIVERSITY INDOOR SPORTS COMPLEX
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3500
Practice Address - Country:US
Practice Address - Phone:631-632-7124
Practice Address - Fax:631-632-3231
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0013272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty