=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073234498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELINE DELISIO MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2022
-----------------------------------------------------
Last Update Date | 09/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 NOANK LEDYARD RD
-----------------------------------------------------
City | MYSTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06355-1361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-742-7219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 SHORE RD
-----------------------------------------------------
City | WESTERLY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02891-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-742-7219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 007021
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------