MEDICARE: EMILY PROVENZANO

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	1816016	NY

General Provider Information

NPI Number	:	1104105683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY PROVENZANO

Provider Business Mailing Address
First Line	:	418 ROBINSON AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1520
Country	:	US
Telephone Number	:	718-556-1616
Fax Number	:

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

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	08/28/2012

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Directions to “ EMILY PROVENZANO ” Practice Location

Language	Start Address	Practice Location

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