Provider Demographics
NPI:1235554635
Name:BALDASSANO, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BALDASSANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6612
Mailing Address - Country:US
Mailing Address - Phone:646-267-9609
Mailing Address - Fax:646-340-4485
Practice Address - Street 1:2460 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6612
Practice Address - Country:US
Practice Address - Phone:646-267-9609
Practice Address - Fax:646-340-4485
Is Sole Proprietor?:No
Enumeration Date:2014-02-22
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist