Provider Demographics
NPI:1770041840
Name:CUNNIFFE FLECKEN, MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CUNNIFFE FLECKEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GIOSASI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:55 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2501
Mailing Address - Country:US
Mailing Address - Phone:631-573-6113
Mailing Address - Fax:
Practice Address - Street 1:55 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2501
Practice Address - Country:US
Practice Address - Phone:631-573-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005615-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005615-1OtherSTATE OF NEW YORK