Provider Demographics
NPI:1689405797
Name:NICOLETTO, TAMARA B
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:B
Last Name:NICOLETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TAMARA
Other - Middle Name:B
Other - Last Name:BELMONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:182 SOUTHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4056
Mailing Address - Country:US
Mailing Address - Phone:631-681-2777
Mailing Address - Fax:
Practice Address - Street 1:182 SOUTHAVEN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4056
Practice Address - Country:US
Practice Address - Phone:631-681-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY$$$$$$$$$222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist