Provider Demographics
NPI:1902362957
Name:VAGELATOS, MICHAELLA
Entity Type:Individual
Prefix:MS
First Name:MICHAELLA
Middle Name:
Last Name:VAGELATOS
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 1:41 EVELYN DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3822
Mailing Address - Country:US
Mailing Address - Phone:631-357-6374
Mailing Address - Fax:
Practice Address - Street 1:41 EVELYN DR
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3822
Practice Address - Country:US
Practice Address - Phone:631-357-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health