MEDICARE: MISS KATERINA THEODORACOPOULOS 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	013463 1	NY

General Provider Information

NPI Number	:	1033420450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KATERINA THEODORACOPOULOS CCC-SLP

Provider Business Mailing Address
First Line	:	4108 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6743
Country	:	US
Telephone Number	:	917-975-0593
Fax Number	:

Provider Business Practice Location Address
First Line	:	4108 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6743
Country	:	US
Telephone Number	:	917-975-0593
Fax Number	:

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

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	12/06/2016

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Directions to “ MISS KATERINA THEODORACOPOULOS CCC-SLP” Practice Location

Language	Start Address	Practice Location

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