Provider Demographics
NPI:1023393527
Name:POVEROMO, JUDITH ANN (SLP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:POVEROMO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1959
Mailing Address - Country:US
Mailing Address - Phone:631-757-9383
Mailing Address - Fax:
Practice Address - Street 1:158 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768
Practice Address - Country:US
Practice Address - Phone:631-262-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3616235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist