Healthcare Provider Details

I. General information

NPI: 1073037537
Provider Name (Legal Business Name): MICHELLE BRUCELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 JEFFERSON AVE
SAINT JAMES NY
11780-1948
US

IV. Provider business mailing address

296 JEFFERSON AVE
SAINT JAMES NY
11780-1948
US

V. Phone/Fax

Practice location:
  • Phone: 516-216-9745
  • Fax:
Mailing address:
  • Phone: 631-480-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097463
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: