=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104945484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH AND LANGUAGE THERAPY ASSOCIATES OF STATEN ISLAND PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 91 NEW DORP LANE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-351-6604
-----------------------------------------------------
Fax | 718-351-2987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 91 NEW DORP LANE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LISA JIANNETTO
-----------------------------------------------------
Credential | MA CCCSLP
-----------------------------------------------------
Telephone | 718-351-6604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 0116221
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------