MEDICARE: MISS PESSIE ELISA GREEN 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	014304-1	NY

General Provider Information

NPI Number	:	1972818375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PESSIE ELISA GREEN CCC-SLP

Provider Business Mailing Address
First Line	:	1255 E 35TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4821
Country	:	US
Telephone Number	:	718-758-4925
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 E 35TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4821
Country	:	US
Telephone Number	:	718-758-4925
Fax Number	:

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

Provider Enumeration Date	:	08/10/2010
Last Update Date	:	08/10/2010

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