Provider Demographics
NPI:1033538087
Name:MARY DACIERNO SPEECH LANGUAGE PATHOLOGIST PC
Entity Type:Organization
Organization Name:MARY DACIERNO SPEECH LANGUAGE PATHOLOGIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:917-586-2964
Mailing Address - Street 1:52 ROMAN AVE
Mailing Address - Street 2:APT. 4
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2721
Mailing Address - Country:US
Mailing Address - Phone:917-586-2964
Mailing Address - Fax:
Practice Address - Street 1:52 ROMAN AVE
Practice Address - Street 2:APT. 4
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2721
Practice Address - Country:US
Practice Address - Phone:917-586-2964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022956252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03764472Medicaid