Provider Demographics
NPI:1962176321
Name:ROSENTHAL, MICHELLE LEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MONTAUK HWY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8322
Mailing Address - Country:US
Mailing Address - Phone:631-647-9009
Mailing Address - Fax:631-647-8992
Practice Address - Street 1:260 MONTAUK HWY
Practice Address - Street 2:SUITE 8
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8322
Practice Address - Country:US
Practice Address - Phone:631-647-9009
Practice Address - Fax:631-647-8992
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health