Healthcare Provider Details

I. General information

NPI: 1770360570
Provider Name (Legal Business Name): YOURSLPNY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9210 SILVER RD
OZONE PARK NY
11417-2442
US

IV. Provider business mailing address

9210 SILVER RD
OZONE PARK NY
11417-2442
US

V. Phone/Fax

Practice location:
  • Phone: 347-889-1136
  • Fax:
Mailing address:
  • Phone: 347-889-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GLENNIE LLANO
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS-CCC
Phone: 347-889-1136