=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346620234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEA SPEECH-LANGUAGE PATHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2015
-----------------------------------------------------
Last Update Date | 09/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 887 OLD COUNTRY RD
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-591-3288
-----------------------------------------------------
Fax | 631-458-1651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 SHORE RD
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-942-5209
-----------------------------------------------------
Fax | 631-458-1651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. VERONICA CEA
-----------------------------------------------------
Credential | M.S CCC-SLP
-----------------------------------------------------
Telephone | 631-942-5209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 013688
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------