Healthcare Provider Details

I. General information

NPI: 1700208709
Provider Name (Legal Business Name): MKSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E BETHPAGE RD SUITE 5
PLAINVIEW NY
11803-4228
US

IV. Provider business mailing address

125 E BETHPAGE RD SUITE 5
PLAINVIEW NY
11803-4228
US

V. Phone/Fax

Practice location:
  • Phone: 516-731-5588
  • Fax: 516-577-9049
Mailing address:
  • Phone: 516-731-5588
  • Fax: 516-577-9049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03858055
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MS. JOANN SCANLON
Title or Position: EXECUTIVE DIRECTOR
Credential: BCBA, LBA
Phone: 516-731-5588