Provider Demographics
NPI:1356841373
Name:AGHELIAN, ALYSSON
Entity Type:Individual
Prefix:
First Name:ALYSSON
Middle Name:
Last Name:AGHELIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSON
Other - Middle Name:
Other - Last Name:AZRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:73 HICKS LN
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 WATERMILL LN
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4234
Practice Address - Country:US
Practice Address - Phone:516-749-6662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty