MEDICARE: ALISSA MARIE IANTOSCA 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	016068-1	NY

General Provider Information

NPI Number	:	1083868236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA MARIE IANTOSCA CCC-SLP

Provider Business Mailing Address
First Line	:	9 E NOTRE DAME ST
Second Line	:	APARTMENT 2
City	:	GLENS FALLS
State	:	NY
Zip	:	12801-2950
Country	:	US
Telephone Number	:	518-420-6462
Fax Number	:

Provider Business Practice Location Address
First Line	:	429 AVIATION RD
Second Line	:
City	:	QUEENSBURY
State	:	NY
Zip	:	12804-2914
Country	:	US
Telephone Number	:	518-824-2600
Fax Number	:

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

Provider Enumeration Date	:	11/13/2008
Last Update Date	:	07/02/2013

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