Provider Demographics
NPI:1427506104
Name:COLLETTI, TARA (MSSPED)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COLLETTI
Suffix:
Gender:F
Credentials:MSSPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-1213
Mailing Address - Country:US
Mailing Address - Phone:631-581-1007
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3029
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1838938252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency