Healthcare Provider Details

I. General information

NPI: 1629531967
Provider Name (Legal Business Name): JACALYN NOBIS BATES M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 FRAVOR RD
MEXICO NY
13114-3011
US

IV. Provider business mailing address

9824 SHADY LAKE RD
CAMDEN NY
13316-4813
US

V. Phone/Fax

Practice location:
  • Phone: 315-963-8400
  • Fax: 315-963-3848
Mailing address:
  • Phone: 315-334-2845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number013181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: