Provider Demographics
NPI:1376906362
Name:IMBERT, PAUL A (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:IMBERT
Suffix:
Gender:M
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 1:86 CHATSWORTH AVE
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1446
Mailing Address - Country:US
Mailing Address - Phone:716-877-1230
Mailing Address - Fax:
Practice Address - Street 1:86 CHATSWORTH AVE
Practice Address - Street 2:APARTMENT 4
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1446
Practice Address - Country:US
Practice Address - Phone:716-877-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009737-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist