Provider Demographics
NPI:1164011656
Name:LONGO-GOLLINGE, AMANDA (COTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:LONGO-GOLLINGE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:11 COLLFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2417
Mailing Address - Country:US
Mailing Address - Phone:917-974-0522
Mailing Address - Fax:
Practice Address - Street 1:100 DUFFY AVE STE 510
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3636
Practice Address - Country:US
Practice Address - Phone:516-737-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010541224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant