=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669798070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIS CONSALVO GALLO S.L.P
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2010
-----------------------------------------------------
Last Update Date | 04/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CIRCLE PL
-----------------------------------------------------
City | SMALLWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12778-0224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-583-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 CIRCLE PLACE BOX 224
-----------------------------------------------------
City | SMALLWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-583-5024
-----------------------------------------------------
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 | 010378-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------