Provider Demographics
NPI:1346558103
Name:FARAGASSO, KRISTINE ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:ANN
Last Name:FARAGASSO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-3514
Mailing Address - Country:US
Mailing Address - Phone:631-244-2261
Mailing Address - Fax:
Practice Address - Street 1:745 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-3514
Practice Address - Country:US
Practice Address - Phone:631-244-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010590-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist