MEDICARE: SUZANNE DALAL PHD

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	103TS0200X	School Psychologist	1059626	NY

General Provider Information

NPI Number	:	1790085801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE DALAL PHD

Provider Business Mailing Address
First Line	:	24 BROOKLYN AVE
Second Line	:	BROOKLYN AVENUE SCHOOL
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-1222
Country	:	US
Telephone Number	:	516-256-0167
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 BROOKLYN AVE
Second Line	:	BROOKLYN AVENUE SCHOOL
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-1222
Country	:	US
Telephone Number	:	516-256-0167
Fax Number	:

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

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	10/25/2010

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