Provider Demographics
NPI:1124583125
Name:FASANO, MARIA THERESA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:THERESA
Last Name:FASANO
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 1:111 ATLANTIC AVENUE LYNBROOK SCHOOL DISTRICT
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563
Mailing Address - Country:US
Mailing Address - Phone:516-612-5000
Mailing Address - Fax:
Practice Address - Street 1:111 ATLANTIC AVENUE LYNBROOK SCHOOL DISTRICT
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563
Practice Address - Country:US
Practice Address - Phone:516-612-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007911-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist