MEDICARE: MISS ENRIQUA WHITE SLP, TSLD

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	019398	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019398	OTHER	NY	NYS SPEECH PATHOLOGY LICENSE

General Provider Information

NPI Number	:	1346540275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ENRIQUA WHITE SLP, TSLD

Provider Business Mailing Address
First Line	:	2736 COLDEN AVE
Second Line	:	APT 3
City	:	BRONX
State	:	NY
Zip	:	10469
Country	:	US
Telephone Number	:	646-391-9405
Fax Number	:

Provider Business Practice Location Address
First Line	:	2736 COLDEN AVE APT 3
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-4152
Country	:	US
Telephone Number	:	646-391-9405
Fax Number	:

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

Provider Enumeration Date	:	10/26/2010
Last Update Date	:	10/26/2010

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