Healthcare Provider Details

I. General information

NPI: 1992415954
Provider Name (Legal Business Name): MICHAEL ROBERT CIPOLLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAINT GEORGES AVE STE F
AVENEL NJ
07001-1000
US

IV. Provider business mailing address

35 DANVERS CIR
NEWARK DE
19702-2722
US

V. Phone/Fax

Practice location:
  • Phone: 571-356-6742
  • Fax:
Mailing address:
  • Phone: 302-494-9276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS01167200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: