Provider Demographics
NPI:1770297103
Name:MEYERS, MADELINE REBECCA
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:REBECCA
Last Name:MEYERS
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 1:2 MOTT DR
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2418
Mailing Address - Country:US
Mailing Address - Phone:631-428-5912
Mailing Address - Fax:
Practice Address - Street 1:991 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1608
Practice Address - Country:US
Practice Address - Phone:631-676-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231741653106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician