Provider Demographics
NPI:1821569898
Name:IZQUIERDO, SALLY MICHELLE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:MICHELLE
Last Name:IZQUIERDO
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-2411
Mailing Address - Country:US
Mailing Address - Phone:516-331-1587
Mailing Address - Fax:516-216-4321
Practice Address - Street 1:22 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2411
Practice Address - Country:US
Practice Address - Phone:516-331-1587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000446-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst