Healthcare Provider Details

I. General information

NPI: 1629223516
Provider Name (Legal Business Name): MARIAELENA SOMAN M.A., CCC-SLP, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N IDAHO AVE
MASSAPEQUA NY
11758-1316
US

IV. Provider business mailing address

319 N IDAHO AVE
MASSAPEQUA NY
11758-1316
US

V. Phone/Fax

Practice location:
  • Phone: 917-709-3473
  • Fax:
Mailing address:
  • Phone: 917-709-3473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number016810
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-9401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: