MEDICARE: MARIA REYES-PARK M.A.

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	018031-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	018031-1	OTHER	NY	THE UNIVERSITY OF THE STATE OF NEW YORK

General Provider Information

NPI Number	:	1538392766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA REYES-PARK M.A.

Provider Business Mailing Address
First Line	:	41 KEW GARDENS RD APT 2C
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1110
Country	:	US
Telephone Number	:	646-334-7474
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 KEW GARDENS RD APT 2C
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1110
Country	:	US
Telephone Number	:	646-334-7474
Fax Number	:

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

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	10/26/2011

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Directions to “ MARIA REYES-PARK M.A.” Practice Location

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