Provider Demographics
NPI:1326397795
Name:BOON SPEECH THERAPY PC
Entity Type:Organization
Organization Name:BOON SPEECH THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PISAMAI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONYATHITISUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-324-3119
Mailing Address - Street 1:64-05 YELLOWSTONE BLVD.
Mailing Address - Street 2:208A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:917-324-3119
Mailing Address - Fax:
Practice Address - Street 1:64-05 YELLOWSTONE BLVD.
Practice Address - Street 2:208A
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:917-324-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014489320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1467692251OtherSPEECH LANGUAGE PATHOLOGIST