MEDICARE: LISA QUINONES MS 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	016096-1	NY

General Provider Information

NPI Number	:	1649408204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA QUINONES MS CCC-SLP

Provider Business Mailing Address
First Line	:	21 WEST ST
Second Line	:	APT 23H
City	:	NEW YORK
State	:	NY
Zip	:	10006-2920
Country	:	US
Telephone Number	:	917-575-6174
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 RICHMOND AVE
Second Line	:	3RD FLOOR
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1520
Country	:	US
Telephone Number	:	917-575-6174
Fax Number	:

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

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	06/22/2009

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