MEDICARE: LAURELAI HISTED M.S., 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	026118-1	NY

General Provider Information

NPI Number	:	1225587017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURELAI HISTED M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	3246 FAIRMOUNT AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-1446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 HUTCHINSON RIVER PKWY
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-1820
Country	:	US
Telephone Number	:	630-632-2054
Fax Number	:

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

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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