Healthcare Provider Details

I. General information

NPI: 1134754492
Provider Name (Legal Business Name): A STEP FORWORD SPEECH AND LANGUAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 LINCOLN ST
NUTLEY NJ
07110-2532
US

IV. Provider business mailing address

6 LINCOLN ST
NUTLEY NJ
07110-2532
US

V. Phone/Fax

Practice location:
  • Phone: 973-221-3474
  • Fax:
Mailing address:
  • Phone: 973-221-3474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GIANNA PETRILLO
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 973-771-8918