=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790504603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVERSE VOICES SPEECH LANGUAGE PATHOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2151 WASHINGTON AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-344-4344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 GODDARD AVE
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06610-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-344-4344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | CAROLYN N MORILLO
-----------------------------------------------------
Credential | MA-CCC TSLD-BE
-----------------------------------------------------
Telephone | 347-344-4344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------