Healthcare Provider Details

I. General information

NPI: 1366935710
Provider Name (Legal Business Name): MELANIE SULICH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ROUTE 340
SPARKILL NY
10976-1041
US

IV. Provider business mailing address

81 RITA DR
NEW FAIRFIELD CT
06812-4618
US

V. Phone/Fax

Practice location:
  • Phone: 845-398-4057
  • Fax:
Mailing address:
  • Phone: 203-942-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: