Healthcare Provider Details

I. General information

NPI: 1942435607
Provider Name (Legal Business Name): SHARON JOLLY AUDIOLOGY & SPEECH LANGUAGE PATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 GIDNEY AVE SUITE 201
NEWBURGH NY
12550-3116
US

IV. Provider business mailing address

PO BOX 368
CENTRAL VALLEY NY
10917-0368
US

V. Phone/Fax

Practice location:
  • Phone: 845-928-2579
  • Fax:
Mailing address:
  • Phone: 845-928-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000043-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number003002-1
License Number StateNY

VIII. Authorized Official

Name: SHARON A JOLLY
Title or Position: OWNER
Credential: MA CCC/SLP
Phone: 845-928-2579