Provider Demographics
NPI:1316202435
Name:MIRODDI, CHRISTINE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MIRODDI
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 1:25 N YEW ST
Mailing Address - Street 2:101
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1435
Mailing Address - Country:US
Mailing Address - Phone:631-561-9952
Mailing Address - Fax:
Practice Address - Street 1:25 N YEW ST
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1435
Practice Address - Country:US
Practice Address - Phone:631-561-9952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist