Healthcare Provider Details

I. General information

NPI: 1417931601
Provider Name (Legal Business Name): ANTOINETTE HAMIDIAN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 LARCH ST STE 300
SCRANTON PA
18509-2802
US

IV. Provider business mailing address

851 COMMERCE BLVD SUITE 107
DICKSON CITY PA
18519-1677
US

V. Phone/Fax

Practice location:
  • Phone: 570-489-5561
  • Fax: 570-489-5563
Mailing address:
  • Phone: 570-489-5561
  • Fax: 570-489-5563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016274
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016274
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberSL005220 L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL005220 L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: