Provider Demographics
NPI:1659025104
Name:SYSLO, BREANNA MARIE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIE
Last Name:SYSLO
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:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:PLATTEKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12568-0258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:572 ROUTE 6 STE 102
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-4787
Practice Address - Country:US
Practice Address - Phone:845-249-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialist