Provider Demographics
NPI:1710258454
Name:FORMATO, MICHAEL (MS OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:FORMATO
Suffix:
Gender:M
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PAGET LN
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3752
Mailing Address - Country:US
Mailing Address - Phone:516-541-1664
Mailing Address - Fax:
Practice Address - Street 1:101 PAGET LN
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-3752
Practice Address - Country:US
Practice Address - Phone:516-541-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0141391174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist