MEDICARE: FRESH START SPEECH THERAPY PLLC

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1285408435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH START SPEECH THERAPY PLLC

Provider Business Mailing Address
First Line	:	1480 E 71ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5730
Country	:	US
Telephone Number	:	347-583-0304
Fax Number	:

Provider Business Practice Location Address
First Line	:	1480 E 71ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5730
Country	:	US
Telephone Number	:	347-583-0304
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	MICHELLE RENEE MIRLAS
Credential	:	CCC-SLP, TSSLD
Telephone Number	:	347-583-0304

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	11/08/2023

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