Provider Demographics
NPI:1821569898
Name:IZQUIERDO, SALLY MICHELLE (PHD, BCBA-D, LBA, LP)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:MICHELLE
Last Name:IZQUIERDO
Suffix:
Gender:F
Credentials:PHD, BCBA-D, LBA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-2341
Mailing Address - Country:US
Mailing Address - Phone:631-317-0025
Mailing Address - Fax:
Practice Address - Street 1:177 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-2341
Practice Address - Country:US
Practice Address - Phone:631-317-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026348103T00000X
NY000446-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist