Healthcare Provider Details

I. General information

NPI: 1518116391
Provider Name (Legal Business Name): LAURA MICHELLE BLAHA MS CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 MILL POND LN
POUGHQUAG NY
12570-5571
US

IV. Provider business mailing address

28 MILL POND LN
POUGHQUAG NY
12570-5571
US

V. Phone/Fax

Practice location:
  • Phone: 845-223-7936
  • Fax:
Mailing address:
  • Phone: 845-223-7936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number011778-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: