Healthcare Provider Details

I. General information

NPI: 1184375636
Provider Name (Legal Business Name): MONIQUE ZODDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 MAIN ST STE 104
PORT JEFFERSON NY
11777-2262
US

IV. Provider business mailing address

903 MAIN ST STE 104
PORT JEFFERSON NY
11777-2262
US

V. Phone/Fax

Practice location:
  • Phone: 631-704-4865
  • Fax:
Mailing address:
  • Phone: 631-704-4865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number031564
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: