Basic Information
| Provider Information | |||||||||
| NPI: | 1356622062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIRROCCO | ||||||||
| FirstName: | MYRIAH | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 487 CREEKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765132178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542176270 | ||||||||
| FaxNumber: | 9149653883 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 GREENRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149497680 | ||||||||
| FaxNumber: | 9149493525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2011 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1285628552 | 01 | NY | AGENCY NPI # | OTHER | 00355940 | 01 | NY | AGENCY MEDICIAD # | OTHER | WVE061 | 01 | NY | AGENCY MEDICARE # | OTHER |