MEDICARE: DINA MARIE VISKOVICH 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	018596-1	NY

General Provider Information

NPI Number	:	1023393352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DINA MARIE VISKOVICH CCC-SLP

Provider Business Mailing Address
First Line	:	1428 BELL BLVD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11360-1212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 BI COUNTY BLVD
Second Line	:	SUITE 114
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-3988
Country	:	US
Telephone Number	:	718-264-1640
Fax Number	:	718-484-0530

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

Provider Enumeration Date	:	10/18/2011
Last Update Date	:	10/18/2011

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Directions to “ DINA MARIE VISKOVICH CCC-SLP” Practice Location

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