Provider Demographics
NPI:1083884456
Name:SIMON, ILENE P (SLP)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:P
Last Name:SIMON
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 1:494 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1510
Mailing Address - Country:US
Mailing Address - Phone:716-875-3009
Mailing Address - Fax:
Practice Address - Street 1:2128 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-874-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006676-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist