=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629389481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY DANIELLE PELOFSKY M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2010
-----------------------------------------------------
Last Update Date | 06/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 LITTLE PLAINS RD
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-266-4425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 HOLLYWOOD DR
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-3135
-----------------------------------------------------
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 | 019066-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------