Provider Demographics
NPI:1225352073
Name:SCOLLAN, AUDREY JEANNE (MA, CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:JEANNE
Last Name:SCOLLAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 WIRELESS BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3965
Mailing Address - Country:US
Mailing Address - Phone:631-382-7311
Mailing Address - Fax:631-382-7399
Practice Address - Street 1:49 WIRELESS BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3965
Practice Address - Country:US
Practice Address - Phone:631-382-7311
Practice Address - Fax:631-382-7399
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019663-1235Z00000X
NY171M00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist