MEDICARE: MRS. MARINA SHISHKIN M.A. CCC-SLP TSSLD

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	021787-1	NY

General Provider Information

NPI Number	:	1326304254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARINA SHISHKIN M.A. CCC-SLP TSSLD

Provider Business Mailing Address
First Line	:	2617 E 17TH ST APT 4E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3833
Country	:	US
Telephone Number	:	646-829-7969
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 E 13TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2807
Country	:	US
Telephone Number	:	646-829-7969
Fax Number	:

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

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	10/05/2012

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