Provider Demographics
NPI:1679291322
Name:MYSTKOWSKI, JUDITH SUSAN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:SUSAN
Last Name:MYSTKOWSKI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 HUBER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3217
Mailing Address - Country:US
Mailing Address - Phone:631-553-2522
Mailing Address - Fax:
Practice Address - Street 1:290 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2562
Practice Address - Country:US
Practice Address - Phone:631-474-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008322-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant