MEDICARE: TAISHA PELLETIER

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	032310-01	NY

General Provider Information

NPI Number	:	1427770908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAISHA PELLETIER

Provider Business Mailing Address
First Line	:	3470 FORT INDEPENDENCE ST APT 1C
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-4589
Country	:	US
Telephone Number	:	347-641-4580
Fax Number	:

Provider Business Practice Location Address
First Line	:	3470 FORT INDEPENDENCE ST APT 1C
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-4589
Country	:	US
Telephone Number	:	347-641-4580
Fax Number	:

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

Provider Enumeration Date	:	09/13/2022
Last Update Date	:	09/13/2022

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Directions to “ TAISHA PELLETIER ” Practice Location

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