Healthcare Provider Details

I. General information

NPI: 1376179630
Provider Name (Legal Business Name): MICHAEL BAPTISTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

IV. Provider business mailing address

78 MORRIS ST
BRENTWOOD NY
11717-2637
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax:
Mailing address:
  • Phone: 631-220-5334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109197
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: