=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033571781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GABRIELLE ROTHMAN, SLP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2016
-----------------------------------------------------
Last Update Date | 03/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 162ND ST APT 5A
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-597-5708
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 162ND ST APT 5A
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357-2043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-597-5708
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | GABRIELLE B ROTHMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-597-5709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 013960-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------