Provider Demographics
NPI:1265059919
Name:ALTINTAS, MIKAYLA JAYNE
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:JAYNE
Last Name:ALTINTAS
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 1:514 VENETIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6330
Mailing Address - Country:US
Mailing Address - Phone:631-620-4662
Mailing Address - Fax:
Practice Address - Street 1:514 VENETIAN BLVD
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-6330
Practice Address - Country:US
Practice Address - Phone:631-620-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103385104100000X
NY0987091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker