MEDICARE: MR. CARMINE ANTHONY LACERTOSA M.S., CF-SLP, TSSLD

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

General Provider Information

NPI Number	:	1891339560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARMINE ANTHONY LACERTOSA M.S., CF-SLP, TSSLD

Provider Business Mailing Address
First Line	:	643 HUGUENOT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-2621
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2128
Country	:	US
Telephone Number	:	718-442-2219
Fax Number	:

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

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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