MEDICARE: KENIA PERALTA 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
1	235Z00000X	Speech-Language Pathologist	41YS00545900	NJ

General Provider Information

NPI Number	:	1851760680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENIA PERALTA CCC-SLP

Provider Business Mailing Address
First Line	:	5 HIGHFIELD LN
Second Line	:
City	:	NUTLEY
State	:	NJ
Zip	:	07110-1928
Country	:	US
Telephone Number	:	973-542-8065
Fax Number	:

Provider Business Practice Location Address
First Line	:	242 WASHINGTON AVE
Second Line	:	LOWER LEVEL J
City	:	NUTLEY
State	:	NJ
Zip	:	07110-3934
Country	:	US
Telephone Number	:	973-563-8837
Fax Number	:

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

Provider Enumeration Date	:	09/22/2015
Last Update Date	:	09/22/2015

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Directions to “ KENIA PERALTA CCC-SLP” Practice Location

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