MEDICARE: FIRST STEP EARLY INTERVENTION SERVICES

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	252Y00000X	Early Intervention Provider Agency	008351	NY

General Provider Information

NPI Number	:	1447487889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST STEP EARLY INTERVENTION SERVICES

Provider Business Mailing Address
First Line	:	4563 RIDGE RD
Second Line	:
City	:	CANANDAIGUA
State	:	NY
Zip	:	14424-9600
Country	:	US
Telephone Number	:	585-259-5316
Fax Number	:	585-396-7547

Provider Business Practice Location Address
First Line	:	4563 RIDGE RD
Second Line	:
City	:	CANANDAIGUA
State	:	NY
Zip	:	14424-9600
Country	:	US
Telephone Number	:	585-259-5316
Fax Number	:	585-396-7547

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	MRS. LISA R. JOHNSON
Credential	:	CCC-SLP
Telephone Number	:	585-259-5316

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	07/04/2009

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