MEDICARE: JACQUELINE TALL CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1013514637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE TALL CCC-SLP

Provider Business Mailing Address
First Line	:	37 THIRD AVE
Second Line	:
City	:	GARDEN CITY PARK
State	:	NY
Zip	:	11040-5021
Country	:	US
Telephone Number	:	516-388-0698
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 LONGFELLOW AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10474-4809
Country	:	US
Telephone Number	:	718-893-1042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	05/27/2022

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Directions to “ JACQUELINE TALL CCC-SLP” Practice Location

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