Provider Demographics
NPI:1124399209
Name:BRINN, ILYCE S (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ILYCE
Middle Name:S
Last Name:BRINN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:NY
Mailing Address - Zip Code:12775-0481
Mailing Address - Country:US
Mailing Address - Phone:914-799-0695
Mailing Address - Fax:
Practice Address - Street 1:25 BROOKVIEW DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2601
Practice Address - Country:US
Practice Address - Phone:914-799-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013178-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist