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General NPI Number Information
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NPI Number | 1033538087
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Entity Type | Organization
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Legal Business Name | MARY DACIERNO SPEECH LANGUAGE PATHOLOGIST PC
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Dates
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Enumeration Date | 04/07/2014
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Last Update Date | 12/02/2016
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Provider Practice Location Address
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Address Line | 52 ROMAN AVE APT. 4
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City | STATEN ISLAND
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State | NY
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Zip | 10314-2721
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Country | US
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Telephone | 917-586-2964
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Fax |
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Provider Business Mailing Address
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Address Line | 52 ROMAN AVE APT. 4
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City | STATEN ISLAND
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State | NY
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Zip | 10314-2721
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Country | US
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Telephone | 917-586-2964
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | MRS. MARY VITALE
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Credential | M.S. CCC SLP
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Telephone | 917-586-2964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 022956
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License Number State | NY
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