Provider Demographics
NPI:1154832996
Name:MIHALIK, NICOLE RYANN (MA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RYANN
Last Name:MIHALIK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RYANN
Other - Last Name:MIHALIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1 SCOUTING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SCOUTING BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-297-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1179261171252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency