Provider Demographics
NPI:1356982243
Name:KIRIAKOS, ANTHONY MICHAEL (OTR/L)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:KIRIAKOS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 UNION PKWY STE 3
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7427
Mailing Address - Country:US
Mailing Address - Phone:631-676-4185
Mailing Address - Fax:
Practice Address - Street 1:19 ERLWEIN CT
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5507
Practice Address - Country:US
Practice Address - Phone:347-801-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023992225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023992Medicaid
NY023992OtherUNITED HEALTHCARE