MEDICARE: STACIE LEE DIMEZZA 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	010030-1	NY

General Provider Information

NPI Number	:	1417101791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE LEE DIMEZZA CCC-SLP

Provider Business Mailing Address
First Line	:	28 MONUMENT AVE
Second Line	:
City	:	GLENS FALLS
State	:	NY
Zip	:	12801-2213
Country	:	US
Telephone Number	:	518-743-9941
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 MONUMENT AVE
Second Line	:
City	:	GLENS FALLS
State	:	NY
Zip	:	12801-2213
Country	:	US
Telephone Number	:	518-743-9941
Fax Number	:

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

Provider Enumeration Date	:	11/12/2008
Last Update Date	:	11/12/2008

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