=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215244645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORA CAMBOURAKIS M.A., CCC-SLP, TSSLD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 12/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17045 84TH AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11432-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-480-2840
-----------------------------------------------------
Fax | 718-658-5690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7161 DOUGLASTON PKWY
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-229-2601
-----------------------------------------------------
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 | 019118
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------