Healthcare Provider Details

I. General information

NPI: 1013783638
Provider Name (Legal Business Name): MICHAELA GLEASON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 LAWRENCE AVE STE 211
SMITHTOWN NY
11787-3619
US

IV. Provider business mailing address

8 JASMINE LN
KINGS PARK NY
11754-3924
US

V. Phone/Fax

Practice location:
  • Phone: 631-360-2223
  • Fax:
Mailing address:
  • Phone: 516-503-1642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number100861
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: