Provider Demographics
NPI:1003124595
Name:EKSTROM, CATHY JEAN
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:JEAN
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 VIOLET RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:352 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713
Practice Address - Country:US
Practice Address - Phone:631-276-6703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003668-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist