MEDICARE: AGR SPEECH-LANGUAGE PATHOLOGY

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	019762	NY

General Provider Information

NPI Number	:	1689976243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGR SPEECH-LANGUAGE PATHOLOGY

Provider Business Mailing Address
First Line	:	2820 OCEAN PKWY APT 21A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7930
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 OCEAN PKWY APT 21A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7930
Country	:	US
Telephone Number	:	718-536-4488
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	MS. ARLENE RAFAELI
Credential	:
Telephone Number	:	718-536-4488

Provider Enumeration Date	:	12/02/2010
Last Update Date	:	12/02/2010

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