Provider Demographics
NPI:1033428123
Name:LIGHT, KERI GAIL
Entity Type:Individual
Prefix:MRS
First Name:KERI
Middle Name:GAIL
Last Name:LIGHT
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 1:1119 PLAINVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-5533
Mailing Address - Country:US
Mailing Address - Phone:718-868-8446
Mailing Address - Fax:
Practice Address - Street 1:1119 PLAINVIEW AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-5533
Practice Address - Country:US
Practice Address - Phone:718-868-8446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist