MEDICARE: KELLY CARBONE

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	020747	NY

General Provider Information

NPI Number	:	1407399967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY CARBONE

Provider Business Mailing Address
First Line	:	2430 SKILLMAN AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-4524
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 SKILLMAN AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-4524
Country	:	US
Telephone Number	:	718-728-5083
Fax Number	:

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

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	11/30/2016

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Directions to “ KELLY CARBONE ” Practice Location

Language	Start Address	Practice Location

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