MEDICARE: MRS. LINDA MARIE FASULLO 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	007103	NY

General Provider Information

NPI Number	:	1376825349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LINDA MARIE FASULLO M.S. CCC/SLP

Provider Business Mailing Address
First Line	:	5 STURROCK WAY
Second Line	:
City	:	EAST SETAUKET
State	:	NY
Zip	:	11733-1046
Country	:	US
Telephone Number	:	631-941-0103
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 STURROCK WAY
Second Line	:
City	:	EAST SETAUKET
State	:	NY
Zip	:	11733-1046
Country	:	US
Telephone Number	:	631-941-0103
Fax Number	:

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

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	09/15/2011

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