MEDICARE: RAINA DESIREE THORSEN M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	58 017269	NY

General Provider Information

NPI Number	:	1538602115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAINA DESIREE THORSEN M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	28 MERRIMAN AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-2431
Country	:	US
Telephone Number	:	917-538-7347
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 MERRIMAN AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-2431
Country	:	US
Telephone Number	:	917-538-7347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	06/12/2023

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