Healthcare Provider Details

I. General information

NPI: 1306910088
Provider Name (Legal Business Name): JANET FAELLO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MCCULLOCH DR
DIX HILLS NY
11746-8304
US

IV. Provider business mailing address

4 MCCULLOCH DR
DIX HILLS NY
11746-8304
US

V. Phone/Fax

Practice location:
  • Phone: 631-493-9242
  • Fax: 631-493-9242
Mailing address:
  • Phone: 631-493-9242
  • Fax: 631-493-9242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number013877
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: