Healthcare Provider Details

I. General information

NPI: 1356288575
Provider Name (Legal Business Name): ILYSA RIFKIN M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 S WASHINGTON ST
MONROE NC
28112-5570
US

IV. Provider business mailing address

1012 FORBISHIRE DR
MATTHEWS NC
28104-6828
US

V. Phone/Fax

Practice location:
  • Phone: 704-282-6259
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30001308
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: