MEDICARE: ANGELICA PENAGOS BOLIVAR

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	3783561	NY

General Provider Information

NPI Number	:	1699219063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA PENAGOS BOLIVAR

Provider Business Mailing Address
First Line	:	102 PECONIC CT
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5305
Country	:	US
Telephone Number	:	631-742-6351
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 94TH ST
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11372-3824
Country	:	US
Telephone Number	:	718-424-9031
Fax Number	:

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

Provider Enumeration Date	:	12/05/2016
Last Update Date	:	12/05/2016

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Directions to “ ANGELICA PENAGOS BOLIVAR ” Practice Location

Language	Start Address	Practice Location

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