Healthcare Provider Details

I. General information

NPI: 1164897229
Provider Name (Legal Business Name): HEIDI FACCINI CCC/LSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CARMAN RD
DIX HILLS NY
11746-5651
US

IV. Provider business mailing address

241 CEDAR AVE
ISLIP NY
11751-4610
US

V. Phone/Fax

Practice location:
  • Phone: 631-549-5580
  • Fax:
Mailing address:
  • Phone: 631-650-1911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number005396
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: