Healthcare Provider Details

I. General information

NPI: 1336764794
Provider Name (Legal Business Name): SULLIVAN COUNTY MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 OLD ROUTE 17
MONTICELLO NY
12701-7013
US

IV. Provider business mailing address

PO BOX 840
HARRIS NY
12742-0840
US

V. Phone/Fax

Practice location:
  • Phone: 845-707-8400
  • Fax: 845-404-8189
Mailing address:
  • Phone: 845-707-8532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. NINA MARIE TIOLECO
Title or Position: SOLE SHAREHOLDER
Credential: MD
Phone: 347-387-3873