Provider Demographics
NPI:1639648199
Name:SQUILLACIOTI, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SQUILLACIOTI
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 1:407 BAYPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1405
Mailing Address - Country:US
Mailing Address - Phone:516-356-8426
Mailing Address - Fax:
Practice Address - Street 1:407 BAYPORT AVE
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1405
Practice Address - Country:US
Practice Address - Phone:516-356-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency