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NPI Code Detail

MEDICARE: MRS. NICOLE J D'AVERSA M.S.- CCC-SLP

MEDICARE: MRS. NICOLE J D'AVERSA 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
1235Z00000XSpeech-Language Pathologist015056-1NY

General Provider Information

NPI Number : 1528318243
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. NICOLE J D'AVERSA M.S.- CCC-SLP
Provider Business Mailing Address
First Line : 28 GLEN COVE DR
Second Line :
City : GLEN HEAD
State : NY
Zip : 11545-1710
Country : US
Telephone Number : 516-676-4344
Fax Number : 516-676-2196
Provider Business Practice Location Address
First Line : 28 GLEN COVE DR
Second Line :
City : GLEN HEAD
State : NY
Zip : 11545-1710
Country : US
Telephone Number : 516-676-4344
Fax Number : 516-676-2196
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/11/2012
Last Update Date : 09/11/2012

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