=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376984476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAENA MISSERI M.C. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2013
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 AIR PARK DRIVE
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 CULLEN LANE
-----------------------------------------------------
City | MIDDLE ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 022406
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------