Provider Demographics
NPI:1093022485
Name:LICHTENSTADTER, MORDECHAI (SLP)
Entity Type:Individual
Prefix:
First Name:MORDECHAI
Middle Name:
Last Name:LICHTENSTADTER
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 14TH AVE
Mailing Address - Street 2:#6-D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3972
Mailing Address - Country:US
Mailing Address - Phone:718-851-9079
Mailing Address - Fax:
Practice Address - Street 1:5201 14TH AVE
Practice Address - Street 2:#6-D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3972
Practice Address - Country:US
Practice Address - Phone:718-851-9079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY019660OtherLICENSE#