Healthcare Provider Details

I. General information

NPI: 1255602249
Provider Name (Legal Business Name): MS. MICHELE KOLARIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 GREENFIELD RD
SOUTHAMPTON NY
11968-3716
US

IV. Provider business mailing address

41 GREENFIELD RD
SOUTHAMPTON NY
11968-3716
US

V. Phone/Fax

Practice location:
  • Phone: 631-591-4658
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number47051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: