Healthcare Provider Details

I. General information

NPI: 1710470018
Provider Name (Legal Business Name): MELINA SHIVBARAN MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 30TH RD
ASTORIA NY
11102-3639
US

IV. Provider business mailing address

1407 30TH RD
ASTORIA NY
11102-3639
US

V. Phone/Fax

Practice location:
  • Phone: 646-644-0349
  • Fax:
Mailing address:
  • Phone: 646-644-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number029417
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1230032181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: