Provider Demographics
NPI:1386958205
Name:MIHALO, JENNIFER (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIHALO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAMUELS PATH
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764
Mailing Address - Country:US
Mailing Address - Phone:631-921-0354
Mailing Address - Fax:
Practice Address - Street 1:22 SAMUELS PATH
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1920
Practice Address - Country:US
Practice Address - Phone:631-921-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013027-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency