Healthcare Provider Details

I. General information

NPI: 1568413771
Provider Name (Legal Business Name): SPEECH, LANGUAGE & SWALLOWING CONSULTANTS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57190 MAIN RD
SOUTHOLD NY
11971-4750
US

IV. Provider business mailing address

57190 MAIN RD P.O. BOX 1562
SOUTHOLD NY
11971-4750
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-3620
  • Fax:
Mailing address:
  • Phone: 631-765-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number016352-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number016296-1
License Number StateNY

VIII. Authorized Official

Name: MS. LISA ANN KELLY
Title or Position: PRESIDENT
Credential: M.S. CCC-SLP
Phone: 631-765-3620