Provider Demographics
NPI:1235730565
Name:PINO GRISALES, JOHANNA (MS CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:PINO GRISALES
Suffix:
Gender:F
Credentials:MS 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 1:6704 MYRTLE AVE # 1533
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7058
Mailing Address - Country:US
Mailing Address - Phone:929-241-7175
Mailing Address - Fax:
Practice Address - Street 1:575 8TH AVE FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3158
Practice Address - Country:US
Practice Address - Phone:212-221-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030217OtherTHE UNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT