=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003356486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACY SHAPIRO, SLP-CCC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2017
-----------------------------------------------------
Last Update Date | 03/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 DEER VALLEY DR
-----------------------------------------------------
City | NESCONSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11767-1567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-553-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 DEER VALLEY DR
-----------------------------------------------------
City | NESCONSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11767-1567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-553-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MS. STACY BETH SHAPIRO
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 631-553-1536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 010923-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------