Provider Demographics
NPI:1164885752
Name:FASANO, ALEXIS (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3601
Mailing Address - Country:US
Mailing Address - Phone:917-681-6324
Mailing Address - Fax:
Practice Address - Street 1:47 JEROME AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3601
Practice Address - Country:US
Practice Address - Phone:917-681-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025321-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist