Healthcare Provider Details

I. General information

NPI: 1134372899
Provider Name (Legal Business Name): MELISSA R COOKFAIR SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14379 ROUTE 9W
RAVENA NY
12143
US

IV. Provider business mailing address

537 ROUTE 9W
GLENMONT NY
12077-3703
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-3124
  • Fax: 518-756-9476
Mailing address:
  • Phone: 518-436-7888
  • Fax: 518-462-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number006160-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number006160-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: