Provider Demographics
NPI:1356007017
Name:DIANA, ELISABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:DIANA
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 1:75 E HOFFMAN AVE APT 1003
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5055
Mailing Address - Country:US
Mailing Address - Phone:631-316-7111
Mailing Address - Fax:
Practice Address - Street 1:75 E HOFFMAN AVE APT 1003
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5055
Practice Address - Country:US
Practice Address - Phone:631-316-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist