Provider Demographics
NPI:1861820730
Name:KASOUF, MICHELLE VANNELLI
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VANNELLI
Last Name:KASOUF
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 1:7704 BLACK WILLOW
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3600
Mailing Address - Country:US
Mailing Address - Phone:315-935-4341
Mailing Address - Fax:
Practice Address - Street 1:7704 BLACK WILLOW
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3600
Practice Address - Country:US
Practice Address - Phone:315-935-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY785301131222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist